A surgical case of papillary muscle reconstruction and double-CABGs for mitral regurgitation due to ruptured papillary muscle after myocardial infarction

A 76-year-old female patient underwent papillary muscle reconstruction, and d-CABGs a month after the onset of myocardial infarction. Posterior papillary muscle (PPM) was recognized to be ruptured partially, its stump was sewn to original PPM. An ePTFE suture (CV 5) was placed from anterior mitral leaflet to anterior papillary muscle in attempt to reinforce PPM-repair. Carpentier-Edwards ring was inserted and d-CABGs (LITA to LAD and GEA to RCA) were performed, simultaneously. Postoperative examination revealed no regurgitation and no stenosis of bypass grafts during follow-up period of 5 months after the procedure. Papillary muscle reconstruction was effective procedure for MR due to the ruptured papillary muscle.     

Isolated papillary muscle rupture complicating acute pancreatitis

Papillary muscle rupture in the absence of coronary stenoses is a rare event. An isolated infarction of the papillary muscle is involved in most cases, but the pathogenesis is still debated. We describe an anterolateral papillary muscle rupture complicating acute pancreatitis in a patient without significant coronary stenoses and with evidence of coronary spasm. This suggests that an increased susceptibility to coronary spasm and thrombosis, triggered by an acute systemic inflammatory response, may represent a mechanism of selective papillary muscle infarction.     

Traumatic papillary muscle rupture

Papillary muscle rupture caused by blunt chest trauma is a relatively rare cause of mitral incompetence. To date only 25 cases of surgically corrected posttraumatic mitral regurgitation have been reported, of which only eight resulted from rupture of the anterolateral papillary muscle.     

Effectiveness of transesophageal echocardiography in diagnosing complete rupture of the papillary muscle after acute myocardial infarction

We reviewed a case undergoing emergency surgery for acute post-infarction papillary muscle rupture. The patient was a 79-year-old woman transferred to our hospital with cardiogenic shock who required endotracheal intubation. The acute myocardial infarction diagnosis was based on the electrocardiographic findings. She had developed progressively worsening pulmonary edema. No heart murmur was detected. Transthoracic echocardiography demonstrated hyperdynamic cardiac motion and an intracardiac massive turbulent color Doppler signal, but neither mitral regurgitation nor the ruptured papillary muscle head was demonstrated. Her deteriorating condition precluded cardiac catheterization. We performed transesophageal echocardiography (TEE), which demonstrated massive mitral regurgitation and the ruptured anterior papillary muscle connected to normal chordae tendineae and anterior and commissural leaflets. During systole, the head of the ruptured papillary muscle moved like a whip in the left atrium. Emergency surgery was performed. Complete rupture of the anterior papillary muscle head was found, and the mitral valve was replaced with a porcine bioprosthesis (Mosaic #25). Postoperatively, she was weaned from intra-aortic balloon pumping after 2 days and recovered uneventfully. Postoperative coronary angiography demonstrated no significant coronary arterial stenosis. To make the diagnosis of post-infarction papillary muscle rupture, we recommend immediate TEE.     

Mitral valve dysfunction following papillary muscle cryoablation

Cryoablation is recognized as a useful modality for diagnostic mapping, as well as for permanent obliteration of arrhythmogenic foci. This technique has been used to eradicate irritable foci at the base of papillary muscles. We report a case of mitral valve dysfunction requiring valve replacement following cryoablation of the posterior papillary muscle. Based on this experience, we caution against extensive cryoablation of papillary muscle tissue because of the possibility of disrupting mitral valve function.     

Papillary muscle rupture following routine aortic valve replacement

A 56‐year‐old man who underwent routine aortic valve replacement (AVR) for aortic insufficiency suffered a presumed embolic event to a small vessel supplying the posteromedial papillary muscle. This led to papillary muscle rupture, and severe, acute mitral regurgitation requiring emergent mitral valve replacement 6 days postoperatively. Small‐vessel coronary embolization outside the setting of infection/endocarditis leading to infarction and papillary muscle rupture following elective AVR has not been previously described in the literature.     

A successful surgical repair of acute postinfarction mitral papillary muscle rupture]

We reviewed a case who underwent early operation for acute postinfarction papillary muscle rupture. The patient was a 75-year-old male who was admitted to our hospital with cardiogenic shock required endotracheal intubation and intraaortic balloon support. The period to operation was 6 days from the onset of inferior myocardial infarction, and 2 days from the onset of postinfarction papillary muscle rupture. The posterior papillary muscle of mitral valve was totally ruptured and the mitral valve was replaced with a mechanical prosthesis (SJM 27 mm). Postoperative clinical course was not smooth, but the patient was going well. We believe to get good results for early operations of postinfarction papillary muscle rupture unless operative chances were lost.     

Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation

Mitral annuloplasty is the preferred surgical treatment for chronic ischemic mitral regurgitation. Although this is usually successful, leaflet restriction by apical displacement of the posterior papillary muscle tip may cause residual mitral regurgitation. Ventricular remodeling surgery is an effective procedure for surgical relocation of the posterior papillary muscle tip in the setting of a severely dilated left ventricle. Direct relocation of the posterior papillary muscle may be useful for patients with a minimally dilated left ventricle or regional left ventricular geometric changes causing mitral regurgitation. Such a surgical procedure is described.     

A physiological approach to surgery for acute rupture of the papillary muscle

There is controversy regarding the optimal management of patients in whom acute papillary muscle rupture develops. This study evaluates the effect of division of the anterolateral papillary muscle on left ventricular (LV) function and compares two methods of treatment--mitral valve replacement (MVR) and mitral valve repair. Thirteen pigs were placed on cardiopulmonary bypass, and interventions were performed in an isolated beating heart preparation. LV function was assessed with a compliant intraventricular balloon at baseline, after division of the anterolateral papillary muscle (Divided), after repair of the divided papillary muscle (Repair), and finally after MVR. Division of the anterolateral papillary muscle caused a significant deterioration in LV function. Function was maintained at this level after mitral valve repair but deteriorated with MVR. Developed pressure measured at baseline was 179 +/- 13 mm Hg; Divided, 148 +/- 11 mm Hg (p less than 0.05 versus baseline); Repair, 149 +/- 15 mm Hg; and MVR, 95 +/- 8 mm Hg (p less than 0.05 versus Divided) at a balloon volume of 20 ml. These results suggest that LV function is impaired by papillary muscle rupture. Repair of the ruptured papillary muscle is associated with better LV function than is MVR.     

Papillary muscle rupture following acute myocardial infarction.

OBJECTIVES: Papillary muscle rupture following acute myocardial infarction (AMI), which rarely occurs, leads to catastrophic outcomes. We reviewed 6 patients who were diagnosed as having papillary muscle rupture. SUBJECTS AND METHODS: Between February 1986 and September 2002, 6 consecutive patients underwent mitral valve replacement (MVR) for acute mitral regurgitation due to postinfarction papillary muscle rupture (4 men and 2 women, mean age 67 years). Preoperatively, all were in New York Heart Association (NYHA) class IV. All patients had intraaortic balloon pumping, and one needed additional percutaneous cardiopulmonary support. Operations were performed within 1 to 19 days (mean 6.8) after the onset of AMI, and within 24 hours after papillary muscle rupture. Complete ruptures were found in 5 of 6 patients. Four patients had posterior papillary rupture and 2 patients anterior. All patients underwent MVR to preserve the posterior mitral leaflet. Concomitant coronary artery bypass grafting was performed in 5 of 6 patients (mean 1.6 grafts per person) and pulmonary venous isolation for atrial fibrillation in one patient. RESULTS: The cardiopulmonary bypass time ranged from 178 to 325 minutes (mean 236), and the aortic cross clamp time from 123 to 196 minutes (mean 155). Two patients died of low cardiac output syndrome. Of 4 operative survivors, 3 patients were in NYHA class I and one in class II. The mean follow-up term was 21 months. One patient with the pulmonary venous isolation has been in sinus rhythm. All survivors have been doing well without any valve related complications. CONCLUSION: Six patients underwent MVR for the papillary muscle rupture following AMI and the perioperative mortality rate was 33%. All survivors have been well with no cardiac events. We propose that in papillary muscle rupture following AMI emergent surgery should be undertaken as soon as possible, and that concomitant surgery should be performed as thoroughly as possible.     

Papillary muscle rupture following acute myocardial infarction

Objectives: Papillary muscle rupture following acute myocardial infarction (AMI), which rarely occurs, leads to catastrophic outcomes. We reviewed 6 patients who were diagnosed as having papillary muscle rupture. Subjects and Methods: Between February 1986 and September 2002, 6 consecutive patients underwent mitral valve replacement (MVR) for acute mitral regurgitation due to postinfarction papillary muscle rupture (4 men and 2 women, mean age 67 years). Preoperatively, all were in New York Heart Association (NYHA) class IV. All patients had intraaortic balloon pumping, and one needed additional percutaneous cardiopulmonary support. Operations were performed within 1 to 19 days (mean 6.8) after the onset of AMI, and within 24 hours after papillary muscle rupture. Complete ruptures were found in 5 of 6 patients. Four patients had posterior papillary rupture and 2 patients anterior. All patients underwent MVR to preserve the posterior mitral leaflet. Concomitant coronary artery bypass grafting was performed in 5 of 6 patients (mean 1.6 grafts per person) and pulmonary venous isolation for atrial fibrillation in one patient. Results: The cardiopulmonary bypass time ranged from 178 to 325 minutes (mean 236), and the aortic cross clamp time from 123 to 196 minutes (mean 155). Two patients died of low cardiac output syndrome. Of 4 operative survivors, 3 patients were in NYHA class I and one in class II. The mean follow-up term was 21 months. One patient with the pulmonary venous isolation has been in sinus rhythm. All survivors have been doing well without any valve related complications. Conclusion: Six patients underwent MVR for the papillary muscle rupture following AMI and the perioperative mortality rate was 33%. All survivors have been well with no cardiac events. We propose that in papillary muscle rupture following AMI emergent surgery should be undertaken as soon as possible, and that concomitant surgery should be performed as thoroughly as possible.     

Papillary muscle sling and overlapping cardiac volume reduction with aortic valve replacement for valvular cardiomyopathy

A 63-year-old male was admitted to our hospital because of severe aortic regurgitation. The left ventricle was extremely dilated and mild functional mitral regurgitation was detected because of outward displacement of papillary muscles. We used a papillary muscle sling with aortic valve replacement to correct the widened distance between the papillary muscles. A papillary muscle sling when used for reducing tethering at the mitral valve also reduces the posterior left ventricular volume. As well, a transmural longitudinal incision along the left anterior descending artery in the left ventricular free wall was sutured by an overlapping method to reduce the anterior left ventricular volume. The combination of papillary muscle sling and the overlapping method does not need any resection of the cardiac muscle and so would be beneficial for end-stage valvular cardiomyopathy.     

Ceftizoxime level in the myocardium (right atrial muscle and mitral papillary muscle) during open heart surgery

We determined the level of sodium ceftizoxime (CZX) in the right atrium and mitral papillary muscle of 22 adults and 6 children undergoing open-heart surgery, 60 and 120 minutes after intravenous administration of this drug at the dosages of 2 grams for adults and 1 gram for children. The CZX level in the right atrial muscle after 60 minutes was 37.0 micrograms/g in adults and 51.0 micrograms/g in children. The CZX level in the papillary muscle of the mitral valve, determined at 120 minutes was 16.9 micrograms/g. In the present study, we measured the level of the antibiotic CZX in the myocardial tissue during open-heart surgery. The purpose of this was to determine the quantity in which the antibiotic is taken into the myocardial tissue.     

Distant solitary skeletal muscle metastasis from papillary thyroid carcinoma

An unusual case of isolated trapezoid muscle metastasis from a papillary carcinoma of the thyroid gland is described. Although extrathyroidal extension to the soft tissues of the neck may occur, distant metastases are rare in papillary thyroid carcinoma. Skeletal muscle metastasis from a differentiated thyroid carcinoma seems to be extremely rare, even for the follicular type of this cancer, well known for its hematogenous spread to various sites.     

Postpartum rupture of the posteromedial papillary muscle

We report a case of postpartum severe mitral regurgitation caused by papillary muscle rupture in a female with normal coronary arteries. The etiology of papillary muscle rupture was endocarditis from puerperal fever. Clinical stabilization was achieved with extracorporeal membrane oxygenation (ECMO) followed by mitral valve replacement two days later.     

Ceftizoxime level in the myocardium (right atrial muscle and mitral papillary muscle) during open heart surgery

We determined the level of sodium ceftizoxime (CZX) in the right atrium and mitral papillary muscle of 22 adults and 6 children undergoing open-heart surgery, 60 and 120 minutes after intravenous administration of this drug at the dosages of 2 grams for adults and 1 gram for children. The CZX level in the right atrial muscle after 60 minutes was 37.0 μg/g in adults and 51.0 μg/g in children. The CZX level in the papillary muscle of the mitral valve, determined at 120 minutes was 16.9 μg/g. In the present study, we measured the level of the antibiotic CZX in the myocardial tissue during open-heart surgery. The purpose of this was to determine the quantity in which the antibiotic is taken into the myocardial tissue.     

Restoring papillary muscle dimensions during restoration in dilated hearts

Left ventricular papillary muscle geometry is distorted in dilated non-ischemic hearts, and following anterior infarction caused by a wrap around left anterior descending artery occlusion. Loss of the apex creates a spherical left ventricular (LV) chamber, and subsequent dilation causes secondary mitral insufficiency by stretching the annulus, altering tethering of the chords and widening the dimension between the bases of papillary muscles to impair leaflet coaptation. This report will describe an intraventricular way to narrow the widened inter papillary muscle distance toward normal.     

A successful valve repair case of isolated tricuspid regurgitation due to traumatic lacerated papillary muscle of the tricuspid valve

A case of tricuspid valve regurgitation due to a non-penetrating chest trauma was presented. This case involves a 20-year-old man, who was admitted to a nearby hospital because of rib fracture, mandibular fracture, and hemorrhage of the left hemopneumothorax, caused by a traffic accident. Palpitation and chest discomfort were observed at admission time, but there was no follow-up. Tricuspid regurgitation was pointed out during surgery for the mandibular fracture, and he continued follow up treatment at an outpatient clinic. However his palpitation and chest discomfort worsened, and he was admitted to our department 8 month after injury. During surgery to repear the tricuspid valve, a papillary muscle rupture, valve cusp laceration, and anulus dilatation were found. We performed a papillary muscle repair (chorda tendineae reconstruction), valve cusp suture, and annuloplasty. Absence of the left pericardium was observed during the operation. We reported valve repair of traumatic tricuspid regurgitation which with papillary muscle rupture. Due to its rarity and the fact that there has been no reported cases of papillary muscle repair for traumatic tricuspid regurgitation in Japan, we used resarched information on the subject.     

Case of papillary muscle rupture diagnosed by preoperative transesophageal echocardiography

A 46-year-old man with severe mitral regurgitation (MR) was scheduled for emergency surgery for chordae tendae repairment. Preoperative transesophageal echocardiography (TEE) revealed massive MR due to a rupture in the antero-lateral papillary muscle. We changed the operation procedure to mitral valve replacement. It is difficult to diagnose papillary muscle rupture. Therefore, we should perform TEE on the patient with acute MR of unknown origin.     

Surgical management of papillary muscle rupture following acute myocardial infarction

Papillary muscle rupture is a rare but severe complication of acute myocardial infarction. Two cases successfully underwent mitral valve replacement and concomitant coronary artery bypass grafting (CABG) for acute myocardial infarction with the anterior papillary muscle rupture in cardiogenic shock. Each of them needed preoperative massive inotropic infusion, respiratory support and intraaortic balloon pumping assist. The first case was a 76-year-old female. Double vessel disease (seg 7 : 90%, seg 11 : 100%) was revealed by coronary angiography and rupture of the papillary muscle was confirmed by transesophageal echocardiography. The second case was a 69-year-old female. Double vessel disease (seg 2 : 90%, seg 11 : 100%) was revealed and severe mitral regurgitation due to prolapse of the anterior leaflet was confirmed by transthoracic echocardiography. To assess the diagnosis of postinfarction papillary muscle rupture, transthoracic and/or transesophageal echocardiography is mandatory. Coronary angiography is also desirable because concomitant myocardial revascularization may improve the prognosis.