Case Study
Anterior and posterior papillary muscle rupture after myocardial infarction
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 728–730 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313481612 aan.sagepub.com
Hiroyuki Morokuma1, Yuji Katayama1, Shugo Koga1 and Yuji Ogura2
Abstract A 66-year-old man was referred in cardiogenic shock due to acute myocardial infarction. Echocardiography revealed severe mitral regurgitation with prolapse of the posterior mitral leaflet due to papillary muscle rupture. Emergency coronary angiography showed subtotal occlusion of the left circumflex coronary artery. A percutaneous coronary intervention was performed immediately. After inducing percutaneous cardiopulmonary support, emergency mitral valve replacement was carried out. The anterior and posterior papillary muscles attached to the posterior mitral leaflet were completely ruptured. Pathological findings showed massive necrosis.
Keywords Coronary angiography, heart rupture, mitral valve insufficiency, myocardial infarction, papillary muscles, shock, cardiogenic
Introduction Papillary muscle rupture (PMR) after myocardial infarction is a rare complication that leads to acute severe mitral regurgitation, pulmonary edema, and cardiogenic shock. Previous reports have shown that the posterior papillary muscle is ruptured more frequently than the anterior papillary muscle because of differences in the blood supply. Mitral valve surgery is the most radical treatment for PMR, and is associated with high operative mortality.
Case report A 66-year-old man with no previous episode of angina was admitted to a nearby hospital after the sudden onset of chest pain. He was in a shock state, and electrocardiography revealed ST-segment depression in leads V3 to V6. He was referred to our hospital with the diagnosis of cardiogenic shock due to acute myocardial infarction. His systolic blood pressure was 60 mm Hg. Auscultation indicated a systolic murmur at the apex. Echocardiography showed a left ventricular ejection fraction of 62%, no asynergy, and
severe mitral regurgitation, but the etiology was unclear because of a poor study. Emergency coronary angiography was performed, with intubation and intraaortic balloon pump (IABP) support. Coronary angiography showed subtotal occlusion of the left circumflex (LCx) coronary artery and no collateral flow from other branches (Figure 1A). Percutaneous plain old balloon angioplasty was subsequently carried out on the lesion, and revascularization was achieved. The right coronary artery and left anterior descending coronary artery were intact (Figure 1B, C). After coronary revascularization, the shock state continued to develop. Echocardiography revealed massive mitral regurgitation with prolapse of the posterior mitral leaflet due 1 Department of Thoracic and Cardiovascular Surgery, Fukuoka Tokushukai Hospital, Kasuga, Fukuoka, Japan 2 Department of Cardiology, Fukuoka Tokushukai Hospital, Kasuga, Fukuoka, Japan
Corresponding author: Hiroyuki Morokuma, MD, Department of Thoracic and Cardiovascular Surgery, Fukuoka Tokushukai Hospital, 4-5 Sugukita, Kasuga, Fukuoka, 816-0864, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at Purdue University Libraries on June 5, 2015
Morokuma et al.
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Figure 1. (A) Coronary angiography revealing subtotal occlusion (arrow) of the left circumflex coronary artery. (B) The intact right coronary artery. (C) The intact left anterior descending coronary artery. and (D) Transesophageal echocardiography shows prolapse of the posterior mitral leaflet with papillary muscle rupture (arrow).
to PMR (Figure 1D). Percutaneous cardiopulmonary support was initiated immediately. An emergency operation was performed 6 h after the onset, approximately 4 h after arrival at our hospital. After a median sternotomy, cardiopulmonary bypass was established in the standard manner, cardiac arrest was obtained by aortic crossclamping and antegrade cardioplegia. The mitral valve was approached via a left atriotomy. The anterior and posterior papillary muscles attached to the posterior mitral leaflet were completely ruptured. The anterior mitral leaflet was intact (Figure 2). The anterior mitral leaflet and prolapsed posterior leaflet were resected, and mitral valve replacement with partial preservation of the posterior mitral leaflet was performed using an SJM 27-mm mechanical valve (St. Jude Medical, St. Paul, MN, USA). The patient was weaned from cardiopulmonary bypass relatively smoothly with IABP and inotropic support. Weaning from respiratory and IABP support was achieved on postoperative days 3 and 4, respectively. Postoperative blood tests revealed a maximum creatine kinase level of 1878 IUL 1, and maximum creatine kinase level-MB of 179I IUL 1. The postoperative course was uneventful. A percutaneous coronary intervention with a stent for the LCx lesion was carried out on postoperative day 18, and the patient was discharged on day 20. The pathological findings showed massive necrosis in the anterior and posterior papillary muscles.
Figure 2. The anterior mitral leaflet was intact, and the anterior and posterior papillary muscles attached to the posterior mitral leaflet were completely ruptured. AML: anterior mitral leaflet; APM: anterior papillary muscle; PML: posterior mitral leaflet; PPM: posterior papillary muscle.
Discussion The posterior papillary muscle tends to rupture more frequently than the anterior papillary muscle (posterior 75% vs. anterior 25%) because it has a single blood supply from the right coronary artery or LCx.1
Downloaded from aan.sagepub.com at Purdue University Libraries on June 5, 2015
730
Asian Cardiovascular & Thoracic Annals 22(6)
In this very rare case of single-vessel coronary artery disease, the anterior and posterior papillary muscles were ruptured, and pathological findings showed massive necrosis. The reason for the anterior and posterior PMR was considered to be that the LCx was relatively large and mainly supplied blood to the anterior and posterior papillary muscles, and the good left ventricular function because of single-vessel disease and subendocardial infarction resulted in a great shearing force on the ischemic papillary muscle.2 In the treatment of patients with PMR, initial hemodynamic stabilization is mandatory, with an IABP or percutaneous cardiopulmonary support if necessary. Early diagnosis and surgical treatment without delay lead to a good prognosis.3 Among the surgical strategies, a good outcome has been reported after mitral valve repair.4 However, in general, mitral valve replacement is preferred, especially in hemodynamically unstable patients.5 Furthermore, prompt coronary revascularization is also necessary because PMR is associated with acute myocardial infarction.6,7 In our opinion, angioplasty of the culprit lesion should be performed before mitral valve surgery to preserve left ventricular function and obtain a better surgical outcome. When angioplasty is impossible due to anatomical or technical problems, concomitant surgical revascularization should be considered. In our patient, immediate percutaneous cardiopulmonary support and prompt coronary revascularization resulted in a good outcome. This case reveals the variability of the coronary blood supply to the papillary muscle.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Sanders RJ, Neubuerger KT and Ravin A. Rupture of papillary muscles: occurrence of rupture of the posterior muscle in posterior myocardial infarction. Dis Chest 1957; 31: 316–323. 2. Nishimura RA, Schaff HV, Gersh BJ, Holmes DR Jr and Tajik AJ. Early repair of mechanical complications after acute myocardial infarction. J Am Med Assoc 1986; 256: 47–50. 3. Tepe NA and Edmunds LH Jr. Operation for acute postinfarction mitral insufficiency and cardiogenic shock. J Thorac Cardiovasc Surg 1985; 89: 525–530. 4. Rankin JS, Feneley MP, Hickey MS, et al. A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation. J Thorac Cardiovasc Surg 1988; 95: 165–177. 5. Tavakoli R, Weber A, Vogt P, Brunner HP, Pretre R and Turina M. Surgical management of acute mitral valve regurgitation due to post-infarction papillary muscle rupture. J Heart Valve Dis 2002; 11: 20–25. 6. Chevalier P, Burri H, Fahrat F, et al. Perioperative outcome and long-term survival of surgery for acute postinfarction mitral regurgitation. Eur J Cardiothorac Surg 2004; 26: 330–335. 7. Russo A, Suri RM, Grigioni F, et al. Clinical outcome after surgical correction of mitral regurgitation due to papillary muscle rupture. Circulation 2008; 118: 1528–1534.
Downloaded from aan.sagepub.com at Purdue University Libraries on June 5, 2015
Anterior and posterior papillary muscle rupture after myocardial infarction
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 728–730 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313481612 aan.sagepub.com
Hiroyuki Morokuma1, Yuji Katayama1, Shugo Koga1 and Yuji Ogura2
Abstract A 66-year-old man was referred in cardiogenic shock due to acute myocardial infarction. Echocardiography revealed severe mitral regurgitation with prolapse of the posterior mitral leaflet due to papillary muscle rupture. Emergency coronary angiography showed subtotal occlusion of the left circumflex coronary artery. A percutaneous coronary intervention was performed immediately. After inducing percutaneous cardiopulmonary support, emergency mitral valve replacement was carried out. The anterior and posterior papillary muscles attached to the posterior mitral leaflet were completely ruptured. Pathological findings showed massive necrosis.
Keywords Coronary angiography, heart rupture, mitral valve insufficiency, myocardial infarction, papillary muscles, shock, cardiogenic
Introduction Papillary muscle rupture (PMR) after myocardial infarction is a rare complication that leads to acute severe mitral regurgitation, pulmonary edema, and cardiogenic shock. Previous reports have shown that the posterior papillary muscle is ruptured more frequently than the anterior papillary muscle because of differences in the blood supply. Mitral valve surgery is the most radical treatment for PMR, and is associated with high operative mortality.
Case report A 66-year-old man with no previous episode of angina was admitted to a nearby hospital after the sudden onset of chest pain. He was in a shock state, and electrocardiography revealed ST-segment depression in leads V3 to V6. He was referred to our hospital with the diagnosis of cardiogenic shock due to acute myocardial infarction. His systolic blood pressure was 60 mm Hg. Auscultation indicated a systolic murmur at the apex. Echocardiography showed a left ventricular ejection fraction of 62%, no asynergy, and
severe mitral regurgitation, but the etiology was unclear because of a poor study. Emergency coronary angiography was performed, with intubation and intraaortic balloon pump (IABP) support. Coronary angiography showed subtotal occlusion of the left circumflex (LCx) coronary artery and no collateral flow from other branches (Figure 1A). Percutaneous plain old balloon angioplasty was subsequently carried out on the lesion, and revascularization was achieved. The right coronary artery and left anterior descending coronary artery were intact (Figure 1B, C). After coronary revascularization, the shock state continued to develop. Echocardiography revealed massive mitral regurgitation with prolapse of the posterior mitral leaflet due 1 Department of Thoracic and Cardiovascular Surgery, Fukuoka Tokushukai Hospital, Kasuga, Fukuoka, Japan 2 Department of Cardiology, Fukuoka Tokushukai Hospital, Kasuga, Fukuoka, Japan
Corresponding author: Hiroyuki Morokuma, MD, Department of Thoracic and Cardiovascular Surgery, Fukuoka Tokushukai Hospital, 4-5 Sugukita, Kasuga, Fukuoka, 816-0864, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at Purdue University Libraries on June 5, 2015
Morokuma et al.
729
Figure 1. (A) Coronary angiography revealing subtotal occlusion (arrow) of the left circumflex coronary artery. (B) The intact right coronary artery. (C) The intact left anterior descending coronary artery. and (D) Transesophageal echocardiography shows prolapse of the posterior mitral leaflet with papillary muscle rupture (arrow).
to PMR (Figure 1D). Percutaneous cardiopulmonary support was initiated immediately. An emergency operation was performed 6 h after the onset, approximately 4 h after arrival at our hospital. After a median sternotomy, cardiopulmonary bypass was established in the standard manner, cardiac arrest was obtained by aortic crossclamping and antegrade cardioplegia. The mitral valve was approached via a left atriotomy. The anterior and posterior papillary muscles attached to the posterior mitral leaflet were completely ruptured. The anterior mitral leaflet was intact (Figure 2). The anterior mitral leaflet and prolapsed posterior leaflet were resected, and mitral valve replacement with partial preservation of the posterior mitral leaflet was performed using an SJM 27-mm mechanical valve (St. Jude Medical, St. Paul, MN, USA). The patient was weaned from cardiopulmonary bypass relatively smoothly with IABP and inotropic support. Weaning from respiratory and IABP support was achieved on postoperative days 3 and 4, respectively. Postoperative blood tests revealed a maximum creatine kinase level of 1878 IUL 1, and maximum creatine kinase level-MB of 179I IUL 1. The postoperative course was uneventful. A percutaneous coronary intervention with a stent for the LCx lesion was carried out on postoperative day 18, and the patient was discharged on day 20. The pathological findings showed massive necrosis in the anterior and posterior papillary muscles.
Figure 2. The anterior mitral leaflet was intact, and the anterior and posterior papillary muscles attached to the posterior mitral leaflet were completely ruptured. AML: anterior mitral leaflet; APM: anterior papillary muscle; PML: posterior mitral leaflet; PPM: posterior papillary muscle.
Discussion The posterior papillary muscle tends to rupture more frequently than the anterior papillary muscle (posterior 75% vs. anterior 25%) because it has a single blood supply from the right coronary artery or LCx.1
Downloaded from aan.sagepub.com at Purdue University Libraries on June 5, 2015
730
Asian Cardiovascular & Thoracic Annals 22(6)
In this very rare case of single-vessel coronary artery disease, the anterior and posterior papillary muscles were ruptured, and pathological findings showed massive necrosis. The reason for the anterior and posterior PMR was considered to be that the LCx was relatively large and mainly supplied blood to the anterior and posterior papillary muscles, and the good left ventricular function because of single-vessel disease and subendocardial infarction resulted in a great shearing force on the ischemic papillary muscle.2 In the treatment of patients with PMR, initial hemodynamic stabilization is mandatory, with an IABP or percutaneous cardiopulmonary support if necessary. Early diagnosis and surgical treatment without delay lead to a good prognosis.3 Among the surgical strategies, a good outcome has been reported after mitral valve repair.4 However, in general, mitral valve replacement is preferred, especially in hemodynamically unstable patients.5 Furthermore, prompt coronary revascularization is also necessary because PMR is associated with acute myocardial infarction.6,7 In our opinion, angioplasty of the culprit lesion should be performed before mitral valve surgery to preserve left ventricular function and obtain a better surgical outcome. When angioplasty is impossible due to anatomical or technical problems, concomitant surgical revascularization should be considered. In our patient, immediate percutaneous cardiopulmonary support and prompt coronary revascularization resulted in a good outcome. This case reveals the variability of the coronary blood supply to the papillary muscle.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Sanders RJ, Neubuerger KT and Ravin A. Rupture of papillary muscles: occurrence of rupture of the posterior muscle in posterior myocardial infarction. Dis Chest 1957; 31: 316–323. 2. Nishimura RA, Schaff HV, Gersh BJ, Holmes DR Jr and Tajik AJ. Early repair of mechanical complications after acute myocardial infarction. J Am Med Assoc 1986; 256: 47–50. 3. Tepe NA and Edmunds LH Jr. Operation for acute postinfarction mitral insufficiency and cardiogenic shock. J Thorac Cardiovasc Surg 1985; 89: 525–530. 4. Rankin JS, Feneley MP, Hickey MS, et al. A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation. J Thorac Cardiovasc Surg 1988; 95: 165–177. 5. Tavakoli R, Weber A, Vogt P, Brunner HP, Pretre R and Turina M. Surgical management of acute mitral valve regurgitation due to post-infarction papillary muscle rupture. J Heart Valve Dis 2002; 11: 20–25. 6. Chevalier P, Burri H, Fahrat F, et al. Perioperative outcome and long-term survival of surgery for acute postinfarction mitral regurgitation. Eur J Cardiothorac Surg 2004; 26: 330–335. 7. Russo A, Suri RM, Grigioni F, et al. Clinical outcome after surgical correction of mitral regurgitation due to papillary muscle rupture. Circulation 2008; 118: 1528–1534.
Downloaded from aan.sagepub.com at Purdue University Libraries on June 5, 2015
