Application of transcatheter edge-to-edge repair in the treatment of papillary muscle rupture of mitral valve after acute myocardial infarction

A cute severe valvular regurgitation is a surgical emer- gency, but accurate and timely diagnosis can be difficult.Although cardiovascular collapse is a common presentation, examination findings to suggest acute regurgitation may be subtle, and the clinical presentation may be nonspecific.Consequently, the presentation of acute valvular regurgitation may be mistaken for other acute conditions, such as sepsis, pneumonia, or nonvalvular heart failure.Although acute regurgitation may affect any valve, acute regurgitation of the left-sided valves is more common and has greater clinical impact than acute regurgitation of right-sided valves.Data to guide appropriate management of patients with acute regurgitation are sparse; there are no randomized trials, and much of the literature describes either small series or the experiences of specific centers.Despite these limitations, the available data are sufficient to allow identification of general principles as well as development of applicable guidelines from both the American College of Cardiology/American Heart Association and European Society of Cardiology.2][3] The data and guidelines emphasize overarching clinical principles, including the need for a high clinical suspicion of acute regurgitation, timely use of echocardiography, and, in the majority of patients, rapid progression to surgery. CausesCauses of acute regurgitation overlap with causes of chronic regurgitation and vary depending on the valve affected (Table 1).Endocarditis may affect either the aortic or mitral valve, whereas other causes are unique to the specific valve involved.The majority of causes of acute regurgitation present as an acute or subacute event.However, acute regurgitation can occur in patients with chronic regurgitation, when regurgitant severity is exacerbated by factors such as coronary ischemia, chordal rupture, or leaflet perforation from endocarditis.Acute regurgitation of either the aortic or mitral valve may result from procedural complications of percutaneous valve procedures.In addition, acute prosthetic valve regurgitation is seen more frequently as more patients undergo valve surgery.Acute prosthetic valve regurgitation is usually due to a tear of a bioprosthetic leaflet 4 or thrombosis of a mechanical valve, although perivalvular regurgitation can occur, particularly in prosthetic valve endocarditis.Acute aortic regurgitation is most commonly due to endocarditis, but there are a variety of less common causes as well.Aortic dissection, whether due to Marfan syndrome, bicuspid aortic valve, or atherosclerotic disease, may present with aortic regurgitation.Blunt trauma may result in leaflet rupture. 5Another less common cause is rupture of a fenestration in the aortic leaflet. 6cute mitral regurgitation may result from either "organic" or "functional" causes.Organic causes are those that result in permanent structural disruption of the valve, such as leaflet perforation from endocarditis, chordal rupture in myxomatous valve disease, or papillary muscle rupture due to myocardial infarction.Functional mitral regurgitation results from abnormalities of the left ventricle, such as cardiomyopathies in which the papillary muscles are laterally displaced, or acute ischemia, in which an akinetic wall segment and papillary muscle impair mitral valve closure.The distinction between organic and functional causes is an important one because treatment of organic causes requires surgical repair, whereas functional causes may improve with treatment of the underlying myocardial ischemia, infarction, or cardiomyopathy.Functional mitral regurgitation is more often chronic than acute.However, processes that result in rapid decline of ventricular function may cause acute functional mitral regurgitation as part of the presentation of acute heart failure.8][9] Emphasizing the variability in pathological process, a study demonstrated that mitral regurgitation in Takotsubo cardiomyopathy can result from outflow tract obstruction and systolic anterior mitral leaflet motion due to apical ballooning with preserved basal ventricular function. 9Rheumatic carditis can cause acute mitral regurgitation through a combination of leaflet inflammation and myocardial dysfunction, with some data suggesting that the degree of valve dysfunction drives outcomes. 10Although uncommon in industrialized nations, acute rheumatic carditis remains a significant issue in developing countries.

75-Year-Old Man With Chest Pain and Dyspnea

Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized.

To evaluate the association between transcatheter edge-to-edge repair (TEER) and outcomes in patients with significant mitral regurgitation (MR) following acute myocardial infarction (MI), focusing on the aetiology of acute post-MI MR in high-risk surgical patients. The International Registry of MitraClip in Acute Mitral Regurgitation following Acute Myocardial Infarction (IREMMI) includes 187 patients with severe MR post-MI managed with TEER. Of these, 176 were included in the analysis, 23 (13%) patients had acute papillary muscle rupture (PMR) and 153 (87%) acute secondary MR. The mean age was 70 ± 10 years and 41% were female. PMR patients had fewer cardiovascular risk factors: hypertension (52% vs. 73%, p = 0.04), diabetes (26% vs. 48%, p < 0.01) but a higher left ventricular ejection fraction (45± 15% vs.35± 10%, p < 0.01) compared secondary MR patients. PMR patients were more likely to present in cardiogenic shock (91% vs. 51%, p = 0.001), require mechanical circulatory support (74% vs. 34%, p = 0.01), and had a higher EuroSCORE II (23± 13% vs. 13± 11%, p = 0.011). The median time from MI to TEER was shorter in PMR (6 days) versus secondary MR (20 days) (p < 0.01). Procedural success was similar (87% vs. 92%, p = 0.49) with comparable MR grade reduction. However, PMR patients had significantly higher in-hospital mortality rates (adjusted odds ratio [OR] 3.05, 95% confidence interval [CI] 1.15-8.12, p = 0.02), 30-day mortality rates (unadjusted OR 3.99, 95% CI 1.42-11.26, p = 0.01) and a higher rate of conversion to surgical mitral valve replacement (22% vs. 3%, p < 0.01) (unadjusted OR 8.17, 95% CI 2.15-30.96, p < 0.001). Aetiology of MR, cardiogenic shock, and procedure timing significantly impacted in-hospital mortality. After adjusting for EuroSCORE II and cardiogenic shock, MR aetiology remained the strongest predictor (adjusted OR 6.71; 95% CI 2.06-21.86, p < 0.01). Transcatheter edge-to-edge repair may be considered a salvage or bridge procedure in decompensated post-MI MR patients of both aetiologies; however, patients with PMR have a higher risk of mortality and conversion to surgery.

IntroductionPapillary muscle rupture is a catastrophic complication of acute myocardial infarction (AMI). Delayed diagnosis and recognition often lead to refractory cardiogenic shock, which is difficult to manage. We present a...

Rupture of Papillary Muscles: Occurrence of Rupture of the Posterior Muscle in Posterior Myocardial Infarction

Rescue transventricular off-pump mitral valve repair with artificial neochords for acute mitral regurgitation due to postinfarction papillary muscle rupture.

Acute ischemic mitral regurgitation is a rare but potentially catastrophic complication following acute myocardial infarction (AMI), characterized by severe clinical presentation and high mortality. Meanwhile, advancements in primary percutaneous coronary intervention (PCI) have reduced the incidence of acute mitral regurgitation (AMR). The surgical approach remains the standard treatment but is associated with high rates of complications and in-hospital mortality, particularly in patients with cardiogenic shock or mechanical complications, such as papillary muscle rupture. Mitral transcatheter edge-to-edge repair (M-TEER) has emerged as a minimally invasive treatment. Current evidence demonstrates the feasibility and safety of M-TEER in reducing mitral regurgitation, stabilizing hemodynamics, and improving in-hospital and short-term survival. The procedural success rate is high, with notable symptoms and functional status improvements. Mortality rates remain significant, reflecting the severity of AMR, but are lower compared to medical management alone. Challenges remain regarding the optimal timing of M-TEER, long-term device durability, and patient selection criteria. Ongoing iterations in device technology and procedural techniques are expected to enhance outcomes. This review highlights the role of M-TEER in AMR management, emphasizing the need for multidisciplinary decision-making and further research to refine M-TEER application and improve outcomes in this high-risk AMR population.

Background Acute mitral regurgitation (MR) is an emergency, often requiring urgent surgery. Severe acute MR presenting with hemodynamic collapse is usually caused by papillary muscle rupture or dysfunction after acute myocardial infarction (AMI) or chordal rupture, resulting in flail mitral leaflet(s). Preoperative stabilization is complex due to concomitant hemodynamic collapse and hypoxic respiratory failure. Finding the right balance between both preload and inotropic support is challenging. When patients are too sick for immediate surgical intervention, mechanical circulatory support can be considered because of its ability to both unload and reduce of cardiac work while increasing coronary perfusion and cardiac output. Nevertheless, even after initial stabilization, surgical risk remains high in critically ill acute severe MR patients and transcatheter treatments such as MitraClip are increasingly being explored. Methods Between August 2017 and September 2019, patients presenting with acute severe mitral regurgitation and considered too ill for immediate surgical intervention (EURO-II score &amp;gt;11.2% plus pulmonary oedema necessitating mechanical ventilation and/or hemodynamic instability), were selected for an Impella-assisted LV unloading technique as bridge to MitraClip-procedure. Five patients were selected for the combined left Impella/MitraClip-procedure in two tertiary cardiac ICUs. Results The mean age was 72 years. The cause of MR was ischemic in 20% and all patients presented in cardiogenic shock state, necessitating mechanical ventilation. The overall cardiac operative risk assessment (Euro-II) score predicted a 35% chance of in-hospital mortality. Cardiac output was severely impaired (mean LVOT VTI 8.2 cm). All patients were on inotropic support and supported by an Impella-CP pVAD (mean flow 2.5 Liter per minute; mean 6.3 days of support). In all cases, we managed to reduce the LVEDP below 15 mmHg using the combination of medical therapy (afterload reduction, inotropes), mechanical ventilation and pVAD-therapy. The MR was significantly reduced by a MitraClip-procedure in each Impella supported patient. The overall survival at discharge was 80%. One patient with late referral and multiple organ failure at presentation deceased due to refractory cardiogenic shock. Overall, severe MR was reduced to grade 1+ and all four patients survived 6 months after discharge with only one readmission for decompensated heart failure. Conclusions A combined strategy of Impella and MitraClip appears to be a novel, feasible alternative for patients presenting with acute, severe MR unable to proceed to a corrective surgical procedure at presentation due to severe left ventricular forward flow failure. In these cases, the early initiation of pVAD-support may reduce the risk of development of irreversible end- organ damage and dysfunction. Exploration in a larger, randomised population is warranted to investigate this strategy further. Funding Acknowledgement Type of funding source: None

Restrictive mitral annuloplasty in refractory cardiogenic shock with acute postinfarction mitral insufficiency and intact papillary muscle

Acute mitral regurgitation (MR) due to papillary muscle rupture (PMR) is a rare but lethal mechanical complication of acute myocardial infarction (MI). The treatment of patients with post-MI PMR, especially those with cardiogenic shock, presents great challenges due to the high surgical risk. We report an 80-year-old woman with a history of hypertension and diabetes mellitus, presented with chest pain. Despite an early percutaneous coronary intervention and transfer to the intensive care unit, her general condition and hemodynamic parameters continued to deteriorate rapidly. Evidenced by electrocardiogram, echocardiogram and coronary angiography, the patient was diagnosed with acute lateral and posterior ST-segment elevation MI, cardiogenic shock, PMR, severe MR, and pulmonary edema. The patient received percutaneous mitral valve repair with MitraClip (Abbott Vascular, Santa Clara, CA, USA) supported by extracorporeal membranous oxygenation and intra-aortic balloon pump. The patient was discharged with relief of heart failure symptoms, reduced MR, and recovery of cardiac function, remaining in a stable condition in New York Heart Association class I after 15-month outpatient follow up. Transcatheter edge-to-edge repair with MitraClip can serve as a viable alternative to surgery in reducing MR in post-MI PMR patients at high surgical risk.

Unileaflet Mitral Valve in Patient With Marfanoid Habitus

We experienced a case with acute mitral regurgitation caused by complete posterior papillary muscle rupture as complication of acute inferior myocardial infarction, who underwent successfully emergency operation of mital valve replacement and coronary revascularization in acute stage. A 64-year-old woman developed sudden cardiogenic shock shortly after the onset of acute inferior myocardial infarction. The diagnosis of acute inferior myocardial infarction was based on the electrocardiographic findings. Under IABP support, preoperative coronary angiography visualized total occlusion of segment 3 of the right coronary artery, and preoperative left ventriculography showed akinesis of inferior wall and severe mitral regurgitation. At 6 hours after onset of papillary muscle rupture, emergency operation was performed. At operation, posterior papillary muscle was found to be totally ruptured. Coronary artery revascularization and mitral valve replacement were performed. Postoperative course was uneventful, with 4 days of IABP and 5 days of ventilatory support. She was discharged on the twentieth postoperative day in NYHA class I. Reports of successful emergency operation for total papillary muscle rupture following acute myocardial infarction are rare. Early diagnosis and surgical treatment are mandatory to save this group of patients.

Papillary muscle rupture (PMR) is a rare and fatal complication of acute myocardial infarction (AMI). We report a case of acute mitral regurgitation (MR) due to PMR with pulmonary edema and cardiogenic shock following AMI with small myocardial necrosis. An 88-year-old woman was brought to our emergency department in acute respiratory distress, shock, and coma. She had no systolic murmur, and transthoracic echocardiography was inconclusive. Coronary angiography showed obstruction of the posterior descending branch of the right coronary artery. Although the infarction was small, the hemodynamics did not improve. Transesophageal echocardiography established papillary muscle rupture with severe mitral regurgitation 5 days after admission. Thereafter, the patient and her family did not consent to heart surgery, and she eventually died of progressive heart failure. Physicians should be aware of papillary muscle rupture with acute mitral regurgitation following AMI in patients with unstable hemodynamics, no systolic murmur, and no abnormalities revealed on transthoracic echocardiography.

Acute mitral regurgitation due to papillary muscle rupture is a severe complication of acute myocardial infarction. Transcatheter edge-to-edge repair is emerging as an effective alternative to surgical treatment, with encouraging outcomes. Leaflet adverse events are rare and are associated with relapse of significant mitral regurgitation. A 54-year-old man arrived at our hospital with a late presentation of ST-elevation myocardial infarction. During primary percutaneous coronary intervention of the circumflex coronary artery, a partial papillary muscle rupture occurred with acute severe mitral regurgitation and cardiogenic shock. Due to the severe haemodynamic instability, the patient underwent an emergent transcatheter edge-to-edge repair with MitraClip device during Impella support with mitral regurgitation resolution and haemodynamic stabilization. At 2-month follow-up, an interclip leaflet tear occurred with relapse of severe mitral regurgitation, requiring a mitral valve replacement surgery. Acute mitral regurgitation due to papillary muscle rupture is a serious complication of acute myocardial infarction. Management is based on haemodynamic stabilization and surgery. The transcatheter edge-to-edge repair is emerging as a therapeutic alternative in high-risk cases. Leaflet adverse events rarely occur during the transcatheter edge-to-edge repair procedure or before patient discharge. Our case is the first to report a late leaflet adverse event, occurring two months after the procedure and, interestingly, after an acute myocardial infarction conditioning an ischaemic mitral regurgitation. This event may be the result of the progressive adverse remodelling of left ventricular inferolateral akinetic wall, with consequent increase of tethering forces on the posterior leaflet, tensioned in the opposite direction by the clip.