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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic and pathologic findings&#46; Four proposed criteria for papillary muscle rupture &#40;B&#58; arrowhead&#44; D&#58; arrow&#41; are present&#58; &#40;1&#41; mobile masses &#40;&#42;&#41; with erratic motion inside the left ventricle&#44; &#40;2&#41; prolapse and bending of anterior mitral valve leaflet &#40;ALef&#41;&#44; &#40;3&#41; mitral regurgitation &#40;C&#58; arrow&#41;&#44; and &#40;4&#41; ventricular wall motion abnormality with inferolateral wall &#40;ILw&#41; akinesia&#44; not resulting in significant reduction in left ventricular cavity dimensions in systole &#40;B&#41;&#59; D&#58; gross pathology&#59; E&#58; microscopic findings &#40;HE &#215;400&#41;&#46; AoV&#58; aortic valve&#59; ct&#58; chordae tendineae&#59; DAo&#58; descending aorta&#59; HE&#58; hematoxylin-eosin&#59; LA&#58; left atrium&#59; LV&#58; left ventricle&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present a case of post-infarction papillary muscle rupture occurring after successful reperfusion of an occluded left circumflex artery&#46; The diagnosis of this increasingly rare complication was made possible by prompt bedside echocardiographic assessment after clinical deterioration&#46; Pathology findings corroborated imaging data&#44; clarifying the relation between irreversible structural disruption and functional consequences in this setting&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 76-year-old overweight and hypertensive female patient admitted to the emergency department because of persistent chest pain at rest starting in the previous four hours&#46; Her 12-lead electrocardiogram showed ST-segment elevation in the DI&#44; aVL and V5-V6 precordial leads&#46; Coronary angiography was performed after transfer to a tertiary hospital within 40 min of admission&#46; It revealed left coronary artery dominance and thrombotic occlusion of the left circumflex artery&#44; for which thrombus aspiration and stent implantation were performed&#46; Echocardiographic assessment showed mildly impaired left ventricular ejection fraction with regional akinesis in both lateral and inferolateral left ventricular wall segments&#46; Sudden pulmonary edema with hypotension 24 hours after admission prompted echocardiographic reassessment&#44; which was notable for posteromedial papillary muscle rupture with severe eccentric mitral valve regurgitation&#46; A Coanda effect across the left atrial posterior wall with anterior leaflet bending and prolapse&#44; and a single color jet in 3-chamber apical view&#44; were in favor of exclusive anterior leaflet involvement &#40;predominant A2 involvement without posterior leaflet involvement&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#8211;C&#41;&#46; A hypermobile papillary muscle with disrupted tip and concurrent significant regurgitation at qualitative color Doppler interrogation &#40;flow convergence without baseline adjustment&#41; provided the diagnosis&#44; with no need for additional quantitative parameters supporting severity&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Intra-aortic balloon pump and inotropic drugs were instituted and the patient was referred for surgical mitral valve intervention&#46; Mitral valve replacement was successfully accomplished with an uneventful recovery&#46; Except for the necrosed and ruptured papillary muscle tip&#44; the submitral apparatus was left in place&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Gross pathologic findings were remarkable&#44; showing the infarcted&#44; ruptured papillary muscle head&#44; irregular borders &#40;z-shaped&#41; at the point of rupture&#44; and interwoven and shrunken free chordae tendineae&#44; explaining the freely mobile margins of the anterior mitral leaflet &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D&#41;&#46; Microscopic examination &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>E&#41; revealed coagulation necrosis&#44; neutrophil infiltration&#44; cell debris&#44; hemorrhage and fibrin deposition at the papillary muscle rupture zone &#40;hematoxylin-eosin &#215;400&#41;&#46; This was consistent with irreversible tissue damage&#44; which explains the papillary muscle tip disruption&#44; leaflet eversion and functional consequences with severe regurgitation at echocardiographic assessment&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The posteromedial muscle usually receives its blood supply exclusively from the right coronary artery&#44; except when there is left coronary dominance&#46; Post-myocardial infarction papillary muscle rupture is a rare and unexpected complication in the current era of coronary reperfusion&#44; particularly when this is performed in due time&#44; as in this case&#46; Nevertheless&#44; its outcome is extremely adverse&#44; with high mortality if it is not immediately recognized and is left under medical therapy&#46; Preservation of the subvalvular apparatus&#44; lower preoperative risk and absence of inotropic drug support are strong independent predictors of better overall long-term survival after surgery&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Echocardiography at the bedside enables rapid and accurate diagnosis of post-myocardial infarction mechanical complications&#44; with earlier surgical referral&#46; Nonetheless&#44; correlation with pathology still clarifies the mechanisms of disease and organic valve dysfunction in this setting&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">MC&#44; JA&#44; RR and RG were responsible for the original idea&#44; clinical data collection and manuscript writing&#59; MA performed the surgical intervention&#59; RG performed the pathologic interpretation&#46; All the authors reviewed and approved the final manuscript&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic and pathologic findings&#46; Four proposed criteria for papillary muscle rupture &#40;B&#58; arrowhead&#44; D&#58; arrow&#41; are present&#58; &#40;1&#41; mobile masses &#40;&#42;&#41; with erratic motion inside the left ventricle&#44; &#40;2&#41; prolapse and bending of anterior mitral valve leaflet &#40;ALef&#41;&#44; &#40;3&#41; mitral regurgitation &#40;C&#58; arrow&#41;&#44; and &#40;4&#41; ventricular wall motion abnormality with inferolateral wall &#40;ILw&#41; akinesia&#44; not resulting in significant reduction in left ventricular cavity dimensions in systole &#40;B&#41;&#59; D&#58; gross pathology&#59; E&#58; microscopic findings &#40;HE &#215;400&#41;&#46; AoV&#58; aortic valve&#59; ct&#58; chordae tendineae&#59; DAo&#58; descending aorta&#59; HE&#58; hematoxylin-eosin&#59; LA&#58; left atrium&#59; LV&#58; left ventricle&#46;</p>"
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    "en" => array:2 [
      "titulo" => "Imagens em Cardiologia"
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  "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003800000004/v3_201911280959/S0870255118304116/v3_201911280959/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/"
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