Acute Papillary Muscle Rupture Research Articles

Abstract 15299: Cardiogenic Shock and Flash Pulmonary Edema in an Uncommon Nonischemic Nonmyxomatous Spontaneous Rupture of Anterolateral Mitral Valve Papillary Muscle

Introduction: Mitral valve papillary muscle rupture is a rare condition that presents a cardiac emergency requiring rapid identification and treatment. Here we present a case of flash pulmonary edema and cardiogenic shock from severe mitral regurgitation (MR) secondary to spontaneous rupture of the anterolateral papillary muscle. Case Presentation: A 48-year-old female with hypertension presented to the ED with acute shortness of breath. In the ED, she was tachycardiac, hypertensive, tachypnic and saturating 75% on room air. On physical exam a 3/6 systolic murmur was present at the apex. ECG had no signs of ischemia. TTE showed severe MR with a fail anterior mitral leaflet. The patient was intubated and taken emergently to the cath lab for intra-aortic balloon pump placement, TEE (Figure 1A) and coronary angiogram, which was normal (Figure 1B, 1C). She was taken to the OR for successful mitral valve replacement surgery. Discussion: The rapid clinical decline and emergent management of patients who develop cardiogenic shock with pulmonary edema from acute non-ischemic papillary muscle rupture presents a significant challenge for clinicians. The cause of papillary muscle rupture most often occurs due an ischemic event, but can occur spontaneously as in this case. Rapid identification of the etiology of the clinical symptoms is of upmost importance to increase chances of survival. On review, 11 cases have been published between 2000-2015 discussing nonischemic nonmyxomatous spontaneous papillary muscle rupture of which the majority had a posterior muscle rupture. In our case, the 48-year old patient only had mild chordal calcification and essential hypertension and presented with nonischemic nonmyxomatous rupture of the anterolateral muscle. With prompt identification and urgent multidisciplinary team intervention, the patient was eventually discharged after replacement and is doing well at 6 months follow-up.

A Comprehensive Review of Acute Coronary Syndrome

A significant sign of coronary artery disease is the acute coronary syndrome (ACS). Angina pectoris, ST-elevation myocardial infarction, and non-ST-elevation myocardial infarction (NSTEMI) are just a few of the conditions that are grouped together under the general term “ACS.” The main cause of death worldwide is cardiovascular disease, which puts ACS under a heavy financial strain. Reduced blood flow to the heart, primarily as a result of plaque rupture and thrombus development, is a pathogenesis of ACS. Numerous risk factors, both modifiable (such as smoking, hypertension, diabetes, hypercholesterolemia, obesity, and inactivity) and non-modifiable (like age, gender, and inheritance), can lead to the development of ACS. Electrocardiography (ECG), clinical evaluation, history-taking, and cardiac biomarkers are all used in the diagnosis process. For the best management, prompt diagnosis and risk classification are essential. Reperfusion therapy, anti-anginal therapy, and renin-angiotensin blocking are a few of the suggested procedures in treatment techniques that aim to minimise myocardial ischemia and restore coronary blood flow. Long-term management also strongly depends on modifying one’s lifestyle, including giving up smoking, eating a healthy diet, getting regular exercise, and obtaining rehabilitation. Acute cardiac failure, ventricular septum or papillary muscle rupture, arrhythmias, recurrent angina, and other consequences of ACS are also highlighted in the paper. The prognosis varies depending on variables, including persistent myocardial injury and the existence of ventricular arrhythmias; an unfavourable prognosis is frequently related to arrhythmias and is associated with poor left ventricular function. . This article offers a thorough review of ACS and gives readers important information about its pathophysiology, risk factors, diagnosis, therapy, and prognosis.

Biomechanical engineering analysis of an acute papillary muscle rupture disease model using an innovative 3D-printed left heart simulator.

OBJECTIVESThe severity of acute papillary muscle (PM) rupture varies according to the extent and site of the rupture. However, the haemodynamic effects of different rupture variations are still poorly understood. Using a novel ex vivo model, we sought to study acute PM rupture to improve clinical management.METHODSUsing porcine mitral valves (n = 32) mounted within an ex vivo left heart simulator, PM rupture was simulated. The mitral valve was divided into quadrants for analysis according to the PM heads. Acute PM rupture was simulated by incrementally cutting from 1/3 to the total number of chordae arising from 1 PM head of interest. Haemodynamic parameters were measured.RESULTSRupture >2/3 of the chordae from 1 given PM head or regurgitation fraction >60% led to markedly deteriorated haemodynamics. Rupture at the anterolateral PM had a stronger negative effect on haemodynamics than rupture at the posteromedial PM. Rupture occurring at the anterior head of the anterolateral PM led to more marked haemodynamic instability than rupture occurring at the other PM heads.CONCLUSIONSThe haemodynamic effects of acute PM rupture vary considerably according to the site and extent of the rupture. Rupture of ≤2/3 of chordae from 1 PM head or rupture at the posteromedial PM lead to less marked haemodynamics effects, suggesting a higher likelihood of tolerating surgery. Rupture at the anterolateral PM, specifically the anterior head, rupture of >2/3 of chordae from 1 PM head or regurgitation fraction >60% led to marked haemodynamic instability, suggesting the potential benefit from bridging strategies prior to surgery.

Emergency Transcatheter Mitral Valve Edge-to-edge Repair for Acute Ischemic Papillary Muscle Rupture in a Patient with Cardiogenic Shock due to Acute Coronary Syndrome

Emergency Transcatheter Mitral Valve Edge-to-edge Repair for Acute Ischemic Papillary Muscle Rupture in a Patient with Cardiogenic Shock due to Acute Coronary Syndrome

Acute Papillary Muscle Rupture Immediately After ST-Segment Elevation Acute Myocardial Infarction: A Case Report and Review

Papillary Muscle Rupture (PMR) is a rare complication (0.5-5%) with high mortality that usually occurs two to seven days after Acute Myocardial Infarction (AMI). However, rapid diagnosis and concomitant treatment can improve early and long-term outcomes. We describe a rare PMR occurring immediately after AMI. The patient complained of exertional chest pain and dyspnea in cardiogenic shock, and was diagnosed with acute PMR by echocardiography. Electrocardiogram showed STsegment elevation in inferior leads, and the time course of creatinine kinase elevation indicated early onset of AMI. Herein, we describe an unusual PMR immediately after AMI and further review PMR.

Abstract 14887: Look Beyond the Coronaries: A Rare Cause of Acute Papillary Muscle Rupture

A 63-year-old male with numerous cardiac risk factors presented with two hours of rapidly progressing chest pain and shortness of breath. Exam was notable for respiratory distress requiring non-invasive mechanical ventilation and a holosystolic apical murmur radiating to the axilla. He had an elevated troponin and an electrocardiogram with anteroseptal ST depressions. He was diagnosed with a non-ST segment elevation acute coronary syndrome and taken for cardiac catheterization. Surprisingly, no occlusive epicardial disease was discovered. Left ventriculogram revealed engorgement of the left atrium and pulmonary arteries suggestive of severe mitral regurgitation. The mechanism of mitral regurgitation was unclear until transesophageal echocardiography showed a ruptured posteromedial papillary muscle with flail mitral valve, a picture classically caused by myocardial infarction. Cardiac MRI demonstrated preserved LV function with minor inferior apical hypokinesis, nonspecific endocardial late gadolinium enhancement in the inferior segments, and a small LV thrombus. An embolic myocardial infarction targeting a small territory involving posteromedial papillary muscle was thought most probable. The patient then underwent an uneventful mitral valve replacement and recovery. However, he returned two months later with severe biventricular dysfunction and cardiogenic shock with peripheral eosinophilia. Myocardial biopsy confirmed the diagnosis of eosinophilic myocarditis. An exhaustive workup for the etiology of his eosinophilia proved unrevealing; he was consequently diagnosed with the idiopathic subtype. The case highlights a rare but important clinical entity that has a varied phenotype. Our patient presented atypically with an acute papillary muscle rupture that mimicked an acute myocardial infarction, ultimately delaying diagnosis. As evidenced by our case, clinical suspicion of myocarditis should be high in all patients presenting with typical anginal symptoms with mechanical or circulatory compromise in the absence of acute coronary occlusion.

P5572Percutaneous edge-to-edge repair for the treatment of acute decompensated severe mitral regurgitation: a single-centre experience

Abstract Background Patients with acute, decompensated severe mitral regurgitation (MR) are poorly served by surgical or medical treatments and is associated with high mortality. Percutaneous edge-to-edge mitral valve repair (PMVR) with the MitraClip system is potentially a less-invasive life-saving procedure. While PMVR has demonstrated efficacy in stable patients with severe MR, there is limited evidence for its use in patients suffering from prolonged cardiogenic shock, recurrent or persistent pulmonary oedema, and haemodynamic instability. Purpose The aim of this study was to evaluate the effectiveness of emergency PMVR in haemodynamically unstable patients with decompensated MR who were unsuitable for surgical intervention. Methods We performed a retrospective review of all patients who underwent emergency PMVR from January 2015 to January 2019 in a single centre. Inclusion criteria were patients with acute decompensated severe MR and shock (defined at the time of procedure as dependence on one or more of: intravenous (IV) inotropes; afterload reduction for persistent pulmonary oedema; mechanical circulatory support; and invasive respiratory support). Outcome measures were pre- and post-procedural MR severity grade, mortality at six months, and incidence of further mitral valve intervention. Results Of 183 consecutive patients undergoing PMVR, 14 (8%) patients fulfilled the inclusion criteria. Median age was 70 (range 55–88, IQR 23), and 8 were female. At the time of admission, 7 (50%) were in cardiogenic shock and 7 were in persistent pulmonary oedema. MR was functional in 7 (50%) patients and degenerative in 7, of which 4 were secondary to acute papillary muscle rupture. All patients had Grade 4 MR at presentation and were considered too high-risk for surgery by the Heart Team. Median Euroscore II was 14.4 (8.1–54.6, IQR 9.1). Post-procedure, 13 patients (93%) of patients had Grade 3 MR or less. Eleven (79%) patients were successfully weaned from mechanical support and intravenous drugs. The remaining three patients died of persistent arrhythmia, stroke or heart failure within 4 weeks. At six-months, 9 out of 12 patients (75%) were alive and 2 were lost to follow-up. No patients underwent further mitral valve intervention. Conclusions This small case-series suggests that PMVR may be a feasible and life-saving procedure in patients presenting with acute, decompensated severe MR who were unsuitable for surgery. It was associated with reversal of cardiogenic shock and good short-term survival in the majority of patients. These patients are typically considered critically unwell with very high mortality. These promising results may inform larger, prospective studies to manage this otherwise under-served patient cohort.

Mitral valve surgery for acute papillary muscle rupture

Papillary muscle rupture (PMR) is a rare complication of a myocardial infarction. The aim of this study was to review our results of mitral valve surgery for acute PMR. Data from patients undergoing emergent mitral valve surgery for acute PMR between 2011 and 2017 at our institution were reviewed. Outcomes included operative morbidity and mortality, mitral valve reoperation, and hospital readmission. A total of 2479 patients underwent mitral valve surgery during the study period including 24 (1.0%) for PMR. Mean age was 62 years, and two (8.3%) patients had prior open-heart surgery. Overall Society of Thoracic Surgeons predicted risk of mortality was 17.5%. Operative mortality was 12.5% (n = 3) with an observed-to-expected mortality ratio of 0.71. There were no strokes, and new onset dialysis was required in two (8.3%) patients. Mean follow-up was 2.40 ± 1.96 years. Three-year mortality, mitral valve reoperation, and readmission rates were 21.1%, 5.0%, and 45.4%. Expeditious operative intervention for PMR can be associated with acceptable operative and longer-term outcomes.

Diagnosis and Management of Papillary Muscle Rupture Complicating Acute Myocardial Infarction: A Case Report and Review of the Literature

Introduction: The incidence of mechanical complications related to myocardial infarction has decreased over the last decades, and revascularization certainly plays a major role in this change. However, mortality still remains elevated. This is a case of acute papillary muscle rupture secondary to myocardial infarction leading to cardiogenic shock. Case Presentation: A 71-year-old woman presented to an outside hospital complaining of chest pain and shortness of breath. An electrocardiogram was obtained and revealed depression of the ST segments from leads V1 to V4. Troponin I was elevated at 3.0 ng/mL. She was transferred to our facility for a higher level of care. She was found in cardiogenic shock at arrival. A bedside echocardiogram was ordered, which demonstrated papillary muscle rupture with severe mitral regurgitation. A coronary angiogram followed, which diagnosed severe three-vessel disease. After the insertion of an intra-aortic balloon pump, she was transferred emergently to the surgical suite for mitral valve replacement and revascularization. The operation was uneventful. She was discharged to a rehabilitation center after approximately 1 month of hospital stay. Conclusions: Mortality from papillary muscle rupture remains elevated. Survival largely depends on the early surgical repair or the replacement of the mitral valve.

APSC2015-1138 Acute Papillary Muscle Rupture Immediately After ST Segment Elevation Acute Myocardial Infarction

APSC2015-1138 Acute Papillary Muscle Rupture Immediately After ST Segment Elevation Acute Myocardial Infarction

Papillary Muscles Rupture as Delayed Sequelae of Trauma

Background : Spontaneous rupture of papillary muscle from sepsis is extremely rare. Most cases of papillary muscle ruptures are due to myocardial infarction or trauma. We describe a case of spontaneous acute papillary muscle rupture in absence of history of ischemic cardiomyopathy or blunt chest trauma. Case Report: A 42 year-old man was transferred to intensive care unit with signs and symptoms of cardiogenic shock. Past history revealed that he had met with a road traffic accident 19 months ago with fracture mid shaft of left femur. He was treated for the same and failed to have regular follow up visits. Physical examination revealed osteomyelitis at the fractured site with sinus formation and pyrexia. His general condition declined thereafter and expired due to cardiac failure few hours later. At autopsy there was rupture of antero-lateral papillary muscle of mitral valve. Microscopic section of the ruptured papillary muscle revealed formation of focal abscess with neutrophil infiltration. Conclusion: Papillary muscle ruptures are associated with significantly increased morbidity and mortality. Therefore early diagnosis is very important in providing appropriate treatment. This case emphasized the fact that delay in diagnosis and institution of appropriate antimicrobial therapy for sepsis may result in life threatening complications. Although this occurrence is uncommon, papillary muscle necrosis and subsequent rupture must be considered as cause of delayed deaths in cases of road traffic accidents with septicemia.

ANTEROLATERAL PAPILLARY MUSCLE RUPTURE DUE TO AN ISOLATED PAPILLARY MUSCLE INFARCT IN A PATIENT WITH NONISCHEMIC CARDIOMYOPATHY

Acute papillary muscle (PM) rupture is an uncommon, catastrophic cardiac emergency resulting in severe mitral regurgitation, congestive heart failure and cardiogenic shock most often seen in the setting of an acute myocardial infarction. The posteromedial papillary muscle is more susceptible to

English

Acute papillary muscle rupture (PMR) often results in acute, torrential mitral regurgitation and florid pulmonary edema. This catastrophic consequence of a subacute presentation of myocardial infarction is associated with a high mortality rate if not identified quickly. The incidence of PMR has decreased in the era of early percutaneous interventions for acute coronary syndromes. However, the importance of prompt recognition and intervention for this condition is paramount. We present a classic case of PMR and the associated hemodynamics, diagnosis and therapeutic management. This case serves as a guide in unmasking this fatal condition.   Key words: Papillary muscle rupture (PMR), diagnosis, myocardial infarction, pulmonary edema.

Right Atrial Approach for Surgical Repair of Post Infarction Ventricular Septal Defect and Acute Tricuspid Regurgitation with Cardiogenic Shock

A complex case of inferior wall infarction with ventricular septal defect and severe tricuspid valve regurgitation due to acute papillary muscle rupture in a 65 year-old male is described. This constellation of pathological lesions and the surgical approach to the repair have not been previously described.

微小血管の閉塞による僧帽弁乳頭筋断裂の1治験例

乳頭筋断裂は急性心筋梗塞後の重篤な合併症として知られる．今回われわれは，冠動脈に有意狭窄を認めない乳頭筋断裂を経験した．稀な症例であるため報告する．症例は77歳男性．急性心不全，心原性ショックにて搬送され，緊急心臓カテーテル検査を行うも，冠動脈に有意狭窄を認めなかった．右心カテデータと心エコーより急性僧帽弁閉鎖不全症と診断し，大動脈内バルーンパンピング，経皮的心肺補助導入後に緊急手術を施行した．後乳頭筋前尖側が断裂しており，A3の逸脱であった．断裂した乳頭筋は暗紫色に変色しており，虚血の関与が疑われた．残存する乳頭筋も脆弱であることが危惧されたため，弁形成は行わず生体弁にて人工弁置換を行い，術後経過は良好であった．術後の病理検査において，乳頭筋内の微小血管の壁肥厚を認め，新鮮な虚血心筋と陳旧性虚血心筋が混在していた．慢性的な乳頭筋虚血による組織の脆弱性を示唆する稀な所見であった．

Mitral Valve Repair After Papillary Muscle Rupture Through Beating Heart Adjustment of Artificial Chordae Length

Acute papillary muscle rupture results in severe mitral regurgitation and hemodynamic instability, and it carries a poor prognosis with a high mortality rate. We present a case of an 86-year-old woman affected by mitral regurgitation due to an acute posterior papillary muscle rupture. The patient underwent a mitral valve repair with annuloplasty and artificial chordae implantation. The neochorda was sutured to the posterior mitral leaflet and fixed through the left ventricle wall on the epicardium. The neochorda length was determined on the beating heart under echocardiographic view.

Acute Anterolateral Papillary Muscle Rupture in the Absence of Coronary Artery Disease

Acute papillary muscle rupture is usually associated with a myocardial infarction and involves the posteromedial muscle. We present a case of spontaneous rupture of the anterolateral papillary muscle due to an isolated infarct of the papillary muscle in the absence of epicardial coronary artery disease.

A case of acute papillary muscle rupture in a childwith campylobacter enteritis and citrullinaemia

We report a case of acute papillary muscle rupture associated with intercurrent Campylobacter jejuni gastroenteritis in a child with a diagnosis of citrullinaemia, requiring urgent mitral valve replacement.

Results of surgery for irreversible moderate to severe mitral valve regurgitation secondary to myocardial infarction.

Moderate to severe irreversible mitral regurgitation secondary to myocardial infarction is an independent risk factor for reduced long-term survival. Late effects of correction of mitral incompetence concomitant with coronary artery bypass grafting (CABG) are less well known and the choice of mitral valve procedure is still debated. From 1988 to 1998, 93 consecutive patients (mean age 63+/-9 years) were treated for moderate to severe irreversible mitral regurgitation secondary to myocardial infarction; 84 were in NYHA functional class III-IV and 19 were in cardiogenic shock. Thirty-seven patients underwent emergency surgery. Perioperative intraaortic balloon pump (IABP) was necessary in 33 patients. Follow-up ranged from 6 months to 12 years (mean 51 months+/-41). Mitral valve was repaired in 30 patients and replaced in 63. Replacement was preferably performed in patients with major displacement of papillary muscle and in patients with acute papillary muscle rupture. CABG (3.4 distal anastomoses) was performed in all patients and was complete in 92%. Early mortality was 15% (14/93). Multivariable analysis identified need for IABP (P=0.005) and COPD (P=0.02) as risk factors for early death. Emergency surgery had only a trend (P=0.15) for increased mortality; age, low ejection fraction, repair vs. replacement had no influence. Actuarial survival rates at 1, 5 and 10 years were 81, 65 and 56%, respectively. Late survival was similar in patients with replacement or repair (P=0.46). At last follow-up, all but one patient were in NYHA functional class I or II. Combined mitral valve procedure and myocardial revascularization, as complete as possible, for moderate to severe mitral regurgitation secondary to myocardial infarction achieve satisfactory early and late outcome despite the increased operative mortality. Acute papillary muscle rupture, severe restriction of the mitral valve by major displacement of the papillary muscle are better managed by valve replacement.

Percutaneous cardiopulmonary support for the management of catastrophic mechanical complications of acute myocardial infarction

Acute papillary muscle rupture and ventricular septal rupture following myocardial infarction are associated with high mortality. We describe the use of cardiopulmonary support to resuscitate two patients, each with one of the above conditions. Early recognition and rapid deployment of CPS were critical to successful outcome. © 1996 Wiley-Liss, Inc.