Ischemic rupture of the anterolateral papillary muscle

Pleasecitethisarticleinpressas:VieiraC,etal.Ischemicruptureoftheanterolateralpapillarymuscle.RevPortCardiol. 2013.http://dx.doi.org/10.1016/j.repc.2012.06.014

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RevPortCardiol.2013;xxx(xx):xxx---xxx

Revista

Portuguesa

de

Cardiologia

Portuguese

Journal

of

Cardiology

www.revportcardiol.org

CASE

REPORT

Ischemic

rupture

of

the

anterolateral

papillary

muscle

Catarina

Vieira

,

António

Gaspar

,

Miguel

Álvares

Pereira

,

Nuno

Salomé

,

Jorge

Almeida

_,

_Mário

_Jorge

_Amorim

a_{DepartmentofCardiology,HospitaldeBraga,Braga,Portugal}

b_{DepartmentofCardiothoracicSurgery,HospitaldeSãoJoão,Oporto,Portugal}

Received25May2012;accepted4June2012

KEYWORDS

Papillarymuscle; Rupture;

Surgical reimplantation; Echocardiography

Abstract We describe the case of a59-year-old man who presented with chest pain and ST-segmentelevationintheinferiorleads,R>SinV1andSTdepressionintheanteriorleadsdue toproximalocclusionofthefirstobtusemarginal.Primarycoronaryangioplastyandstentingof thisarterywereperformed.Twelvehourslaterthepatientbecamehemodynamicallyunstable andseveremitralregurgitationduetoruptureofoneoftheheadsoftheanterolateralpapillary musclewasdiagnosed.Emergencysurgerywasperformed(papillarymusclehead reimplanta-tion,mitralannuloplastywitharigidring,tricuspidannuloplastyandcoronaryarterybypass grafting).Onsurgicalinspection,itwasobservedthatthedetachedmuscleheadhadbecome trappedintheleftventriclebyasecondarycordattachedtotheotherhead.

This case isunusual in presentingtwo uncommon features ofischemic papillarymuscle: ruptureoftheanterolateralmuscleinmyocardialinfarctioninvolvingtheinferoposteriorwalls, andthefactthattherupturedmuscleheaddidnotprolapsebecauseithadbecometrappedin theleftventriclebysecondarycordattachment.

© 2012 SociedadePortuguesa de Cardiologia. Published by Elsevier España, S.L. All rights reserved.

PALAVRAS-CHAVE

Músculopapilar; Rutura;

Reimplantac¸ão cirúrgica; Ecocardiograma

Ruturaisquémicadomúsculopapilarântero-lateral

Resumo Apresentamosumcasodeumhomem,de59anosdeidade,admitidonoServic¸ode Urgênciapordortorácicaeelevac¸ãoSTnasderivac¸õesinferiores,r>semV1edepressãoSTnas derivac¸õesprecordiais,devidoaoclusãodaprimeiraobtusamarginal.Foirealizadaangioplastia primáriadessalesãocomimplantac¸ãodestentrevestido.Dozehorasdepois,odoente desen-volveinstabilidadehemodinâmica,tendosidodiagnosticadaumainsuficiênciamitralgravepor ruturadeumadascabec¸asdomúsculopapilarântero-lateral.Odoentefoisubmetidoa cirur-giaemergente(reimplantac¸ãodomúsculopapilarântero-lateral,anuloplastiamitralcomanel rígido,anuloplastiatricúspideerevascularizac¸ãomiocárdica).Ainspec¸ãocirúrgicarevelouque acabec¸amuscularrompidasemantinhapresaaoventrículoesquerdoporumacordasecundária quealigavaàoutracabec¸adomúsculopapilarântero-lateral.

∗_{Correspondingauthor.}

E-mailaddress:cfvieira1982@hotmail.com(C.Vieira).

Pleasecitethisarticleinpressas:VieiraC,etal.Ischemicruptureoftheanterolateralpapillarymuscle.RevPortCardiol. 2013.http://dx.doi.org/10.1016/j.repc.2012.06.014

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2 C.Vieiraetal.

Estecasotemaparticularidadedeapresentar2característicasincomunsdaisquemiado mús-culopapilar: rutura domúsculo ântero-lateral num enfarte póstero-inferiore ofacto dea cabec¸ademúsculonãoprolapsarparaaaurículaesquerda,porseencontrarpresaaoventrículo esquerdoporumacordasecundária.

© 2012 SociedadePortuguesa de Cardiologia. Publicado por Elsevier España, S.L.Todos os direitosreservados.

Introduction

Papillary muscle rupture is an infrequent but often

catastrophicmechanical complicationofacutemyocardial infarction (MI) accounting for approximately 5% of early deaths.1_{The conditionmayresultinacutemitral} regurgi-tation,acutepulmonaryedema,and/orcardiogenicshock.2 Despitehighoperativemortality,surgeryisindicatedas sur-vivalofmedicallytreatedpatientsisverylow.3

Wereportanuncommonpresentationofananterolateral papillarymuscle rupture successfully repaired by surgical reimplantationofoneofthepapillarymuscleheads.

Case

report

A 59-year-old man wasadmitted tothe emergency room withacutechestpain.The12-leadECG(Figure1)showedST elevationintheinferiorleads,R>SinV1andSTdepression intheanteriorleads.Thepatientwashemodynamically sta-bleandcardiacandpulmonaryauscultationswerenormal.

Coronary angiography showed obstruction of the prox-imal segment of the first obtuse marginal and significant stenosis (80%) of the proximal segment of the anterior descendingartery.Primarycoronaryangioplastyofthefirst obtuse marginal and implantation of a drug-elutingstent wereperformed. Twelve hourslater the patientsuddenly became hypotensive and tachycardic. Physical examina-tionrevealed a new3/6 holosystolic murmur at the apex and significant bilateral rales. Transthoracic echocardiog-raphyshowedseveremitralregurgitationduetoposterior mitral leaflet prolapse and an image of a mass in the left ventricle, which did not prolapse totally into the left atrium during systole, suggestive of an anterolateral papillary muscle head. Left ventricular size and function wererelativelynormalbuttheposteriorandinferiorwalls were hypokinetic. Moderate tricuspid regurgitation was noticed and pulmonary artery systolic pressure was esti-matedat60mmHg.

Thepatientbecameoliguric,withdeteriorationofrenal function,andsoanintra-aorticballoonwasplacedandhe wastransferred toacardiothoracicdepartment for emer-gencysurgery.

Intraoperative2D/3Dtransesophagealechocardiography confirmedruptureofoneoftheheadsoftheanterolateral papillarymuscle, leading toextensive prolapse of the P1 and P2 segments and causing severe mitral regurgitation

(Figures 2 and 3A and B; videos 1, 2 and 3). On surgical

inspection,itwasobservedthatthedetachedmusclehead

(Figure 4) had become trapped in the left ventricle by a

secondarycordattachedtotheotherhead.Papillarymuscle headreimplantation,mitralannuloplastywitharigidring, tricuspidannuloplastywithaSoveringringanddouble coro-naryarterybypassgrafting(CABG)(leftinternalmammary artery tofirstobtuse marginal and right internal thoracic arterytoanteriordescendingartery)wereperformed.

The postoperative period was complicated by noso-comial pneumonia but the patient recovered fully and was discharged home on the 18th day. Transthoracic echocardiographyperformed15daysaftersurgeryshowed preserved global leftventricular functionand mild mitral regurgitation.

Discussion

The posteromedialpapillarymuscleissupplied withblood fromtheposteriordescendingartery,while the anterolat-eral papillary muscle has a dual blood supply, from the leftanteriordescendingandleftcircumflexarteries.4---6_This differenceinbloodsupplyexplainswhyruptureofthe pos-teromedial papillarymuscle is 6---12 timesmore common. On the other hand, rupture of the anterolateral papillary muscle is usually associated withanterolateral MI, rarely occurringinthecontextofinferiorMI,ashappenedinthe casepresented.7

Transthoracicechocardiographyisusefulinthediagnosis ofpapillarymusclerupture,withasensitivityof65---85%.8 A flail segment of the mitral valve and a severed papil-larymuscleorchordacanfrequentlybeseenmovingfreely withintheleftventricularcavity.However,insomecases, transthoracicechocardiographyisnotinformativeand trans-esophageal echocardiography is required to establish the diagnosis;thisismostlikelytooccurwhentherupturedhead does notprolapse intotheleftatrium,aswasobservedin ourpatient,afeaturereportedinupto35%ofcases.9

Emergencysurgical interventionremainsthetreatment ofchoiceforpapillarymusclerupture.Surgeryinvolves sig-nificant operative mortality (18%), but there are recent trendsforloweroperativerisk,particularlywithassociated CABG(8.7%).10_{Long-termoutcomeaftersurgeryisthesame} as that of similar MI without papillary muscle rupture.10 Theseencouragingobservationsemphasizetheimportance ofpromptdiagnosisandanaggressivetherapeuticapproach forpatientssufferingpapillarymuscleruptureafterMI.

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Ischemicruptureoftheanterolateralpapillarymuscle 3

Figure 1 Electrocardiogram on admission demonstrating slight ST-segment elevation in the inferior leads, R>S in V1 and

ST-segmentdepressionintheanteriorleads.

Figure2 Two-dimensionaltransesophagealechocardiogramshowingseveremitralregurgitationcausedbyposteriorleaflet

pro-lapse.LA:leftatrium;LV:leftventricle.

LA

A

B

LV

LAA Ao

Figure3 Three-dimensionaltransesophagealechocardiography.(A)Fullvolumecroppedimageshowingthedetachedheadofthe

anteriorpapillarymuscleinside theLV(arrow)causingsevereprolapse oftheposterior leaflet;(B)3DZoomofthemitralvalve

Pleasecitethisarticleinpressas:VieiraC,etal.Ischemicruptureoftheanterolateralpapillarymuscle.RevPortCardiol. 2013.http://dx.doi.org/10.1016/j.repc.2012.06.014

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4 C.Vieiraetal.

Figure 4 Intraoperative view showing the forceps holding

thedetachedmusclehead.Thetwoprimarycordsconnecting

themuscleheadtotheedgeoftheposteriorleafletareclearly

seen.

hadbecometrappedintheleftventriclebyacord attach-ment.

Ethical

disclosures

Protection of human and animal subjects.The authors

declarethatnoexperimentswereperformedonhumansor animalsforthisstudy.

Confidentialityofdata.Theauthorsdeclarethattheyhave followedtheprotocolsoftheirworkcenteronthe publica-tionofpatientdataandthatallthepatientsincludedinthe studyreceivedsufficientinformationandgavetheirwritten informedconsenttoparticipateinthestudy.

Righttoprivacyandinformedconsent.Theauthorshave

obtained the written informedconsent of thepatients or subjectsmentionedinthearticle.Thecorrespondingauthor isinpossessionofthisdocument.

Conflicts

of

interest

Theauthorshavenoconflictsofinteresttodeclare.

Appendix

A.

Supplementary

data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.repc.

2012.06.014.

References

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8.Czarnecki A, Thakrar A, Fang T, et al. Acute severe mitral regurgitation:considerationofpapillarymusclearchitecture. CardiovascUltrasound.2008;6:5.

9.MoursiMH,BhatnagarSK,Vilacosta I,SanRomanJA,Espinal MA,NandaNC.Transesophagealechocardiographicassessment ofpapillarymusclerupture.Circulation.1996;94:1003. 10.RussoA,SuriRM,GrigioniF,etal.Clinicaloutcomeafter