Posterior papillary muscle rupture after transapical transcatheter aortic valve implantation

Transapical transcatheter aortic valve implantation is a well-established alternative in patients at a high risk for conventional aortic valve replacement. We performed transapical transcatheter aortic valve implantation on an 83-year-old woman with symptomatic severe aortic stenosis. Intraoperative transoesophageal echocardiography (TOE) after transcatheter aortic valve implantation showed mild mitral regurgitation without intracardiac structural injury. In the intensive care unit, the patient gradually had haemodynamic instability; TOE revealed severe mitral regurgitation with A2 and A3 prolapse due to rupture of the posterior papillary muscle. To repair the mitral regurgitation, mitral valve replacement was performed. Preoperative TOE revealed posterior displacement of the left ventricle due to right ventricular dilatation. Computed tomography showed the insertion angle of the guidewire from the left ventricular apex to the aortic valve as 95.6° and a relatively sharp angle of guidewire through the aortic valve. In such a case, it is necessary to carefully perform the catheter procedures to prevent intracardiac structure injury; posterior papillary muscle is particularly crucial.