Multimodality imaging approach to identify hemodynamic significance of an anomalous papillary muscle insertion: A case report

Anomalous papillary muscle insertion (APMI) has primarily been reported in the context of contributing to left ventricular outflow tract (LVOT) obstruction. However, there is a paucity of cases reporting APMI without LVOT obstruction. This case reports a 61-year-old female who presented with acute neurologic symptoms suggestive of cardioembolic stroke. Transthoracic and transesophageal echocardiography identified a mobile mass on the anterior mitral leaflet without significant valvular abnormality or LVOT obstruction. Cardiac MRI confirmed the diagnosis of APMI without dynamic obstruction and excluded thrombus or tumor. Given the lack of hemodynamic compromise, the patient was managed conservatively without surgical intervention or anticoagulation. This case highlights the utility of multimodality imaging in evaluating rare congenital cardiac anomalies. Cardiac MRI was essential in characterizing APMI and avoiding unnecessary surgical or pharmacologic intervention. The case adds to the limited literature on APMI without LVOT obstruction, particularly in the setting of stroke evaluation.