Severe mitral regurgitation in Tako-Tsubo cardiomyopathy

Severe emotional or physical stress precedes Tako-Tsubo cardiomyopathy (TTC) which is characterized by transient left ventricular impairment in absence of coronary artery disease. In this case we report from a female patient presenting with characteristic features of TTC after examination of upper gastrointestinal. Additionally, severe mitral regurgitation due to acute rupture of the posteromedial papillary muscle was present. Normal left ventricular function was documented before surgical valve repair was performed. TTC is reported to be associated with several complications. This is the first report of TTC accompanied by severe mitral valve regurgitation due to rupture of a papillary muscle.     

Left-to-right shunt at atrial level after rupture of papillary muscle from acute myocardial infarction

Clinical and necropsy observations are described in a patient who developed a large left-to-right shunt at atrial level after rupture of a papillary muscle during acute myocardial infarction. Attention is called to the importance of differentiating this combination from rupture of the ventricular septum and from mitral regurgitation resulting from papillary muscle necrosis with or without rupture.     

Partial papillary muscle rupture complicating acute myocardial infarction:Diagnosis by multiplane transoesophageal echocardiography

Papillary muscle rupture is a rare but generally fatal mechanicalcomplication of acute myocardial infarction. In contrast tocomplete papillary muscle rupture, echocardiographic recognitionof partial papillary muscle rupture has rarely been reportedand seems to be more challenging. We describe a patient withpartial papillary muscle rupture that could only be diagnosedby multiplane transoesophageal echocardiography, whereas transthoracicechocardiography and single plane transoesophageal echocardiographyshowed only posterior mitral leaflet prolapse.     

Transcatheter Mitral Valve Edge-to-Edge Repair with the New MitraClip XTR System for Acute Mitral Regurgitation Caused by Papillary Muscle Rupture

Treatment of patients presenting with cardiogenic shock due to acute mitral regurgitation related to papillary muscle rupture poses significant challenges, owing to the high risk associated with conventional surgery. We hereby report successful transcatheter mitral valve edge-to-edge repair with the new Mitraclip XTR device (Abbott Vascular, Santa Clara, CA) in a patient with acute myocardial infarction and cardiogenic shock. Although surgical intervention remains the standard of care, the new MitraClip XTR system offers a novel treatment option for patients with papillary muscle rupture by overcoming the anatomic challenges often seen in this pathology.     

Papillarmuskelri? w?hrend eines Belastungs-EKGs nach Myokardinfarkt

The case of a 57 year old patient is reported, who suffered from an acute myocardial infarction with maximum CK and CKMB values of 821 and 84 U/l, respectively. The patient underwent bicycle exercise testing 9 days after a myocardial infarction in 25 W steps every 2 min starting with 50 W. The ergometry was interrupted at 125 W because of ST segment depression of 0.28 mV in V6. Systolic blood pressure dropped to 55 mm Hg, combined with severe angina and shock. Volume substitution and catecholamines did not elevate blood pressure. Immediate M-mode and Doppler echo revealed a "stiletto"-shaped mitral regurgitation profile typical of acute mitral valve insufficiency. The transesophageal echocardiogram showed a distinct mass moving between the left ventricle and left atrium, diagnostic of papillary muscle rupture. Despite of shock, mitral valve replacement was performed successfully. To our knowledge, this is the first report of a papillary muscle rupture during exercise testing after myocardial infarction. Papillary muscle rupture can be induced by exercise. This fateful event may not be predicted by the course of the ergometry. In case of hypotension during exercise, papillary muscle rupture should be considered. The diagnosis is to be established by transesophageal echocardiography.     

Spontaneous rupture of the papillary muscle with angiographically normal coronary vessels

Papillary muscle rupture is an unusual pathology, commonly being a mechanical complication of an acute myocardial infarction or a blunt chest trauma. In this case report we describe a patient with a spontaneous complete posteromedial papillary muscle rupture, secondary to an isolated papillary muscle infarction, in the absence of coronary artery disease, resulting in severe mitral regurgitation, cardiogenic shock and uneventful urgent mitral valve replacement. The clinical and histopathologic literature, and mechanisms to explain this kind of rupture, are reviewed.     

Post-traumatic blunt mitral insufficiency: surgical experience and review

Three cases of acute mitral insufficiency after blunt chest trauma are presented. All three patients underwent urgent surgery for mitral valve replacement (MVR). The first patient presented complete detachment of the anterior papillary muscle, while the other two showed rupture of the posterior papillary muscle. The second patient also suffered rupture of the anterior papillary muscle of the tricuspid valve, and subsequently underwent double mitral-tricuspid valve replacement. All patients survived the operation and were discharged in good condition. An extensive review of the literature on surgically managed patients is included. In this group of high-risk patients, MVR represents a rapid and safe operation, and represents a good surgical option.     

Papillary Muscle Rupture Following Non‐ST‐Elevation Myocardial Infarction: A Case Report

Papillary muscle rupture is a serious mechanical complication of acute myocardial infarction typically seen within 5–7 days following transmural ST‐elevation myocardial infarction. The incidence of papillary muscle rupture has markedly decreased in the modern era due to improved diagnosis and early coronary revascularization of ST‐elevation myocardial infarction. As a result, papillary muscle rupture is increasingly seen following non‐ST‐elevation myocardial infarction where both diagnosis and revascularization can be delayed. In this report, we describe two cases of papillary muscle rupture following delayed presentation of non‐ST‐elevation myocardial infarction and delayed recognition of papillary muscle rupture.     

Myocardial embolus to coronary artery: result of rupture of papillary muscle during acute myocardial infarction.

A patient is described with acute myocardial infarction complicated by rupture of a papillary muscle. A surprise finding at necropsy was a fragment of necrotic myocardium, similar to that at the site of papillary muscle rupture, in one coronary artery. Myocardial embolism to a coronary artery has not been described previously to our knowledge.     

Catheter-based fixation of the mitral valve after acute papillary muscle rupture: A new technique for temporary hemodynamic stabilization

We describe a new, catheter-based method for temporary management of hemodynamic instability after papillary muscle rupture in a patient with an acute myocardial infarction. Cathet. Cardiovasc. Intervent. 46:446–449, 1999. © 1999 Wiley-Liss, Inc.     

Cardiogenic shock due to papillary muscle rupture in acute myocardial infarction

We report a case of papillary muscle rupture complicating acute myocardial infarction which resulted in acute cardiogenic shock. The patient underwent urgent replacement of the mitral valve and made an uncomplicated recovery.     

Un infarctus du myocarde compliqué d’une rupture du pilier antérieur de la valve mitrale au cours d’une corticothérapie prolongée

The authors report anterolateral papillary muscle rupture, occurring in a 67-year-old patient admitted for acute coronary syndrome. Mitral regurgitation, a rare but dramatic complication of myocardial infarction, is most often a consequence of posterior papillary muscle rupture. The ‘protection’ of the anterior papillary muscle is associated with vascularization via a dual coronary artery supply. Possible myocardial weakening associated with long-term corticotherapy is otherwise discussed in this observation.     

MRSA-associated bacterial myocarditis causing ruptured ventricle and tamponade

We report a case of an 81-year-old man with bacterial myocarditis presenting with elevated troponins and sepsis, who succumbed due to a ruptured ventricle. The infecting organism was found to be methicillin-resistant Staphylococcus aureus. Bacterial myocarditis is a rare occurrence when independent of infective endocarditis. Generally, this is a complication of bacteremia that is discovered post-mortem. Rarely, as in our patient, it causes significant necrosis of the myocardium leading to rupture of a ventricle. As with viral myocarditis, this disease can present with signs and symptoms of acute myocardial infarction, complicating the diagnosis. Much of the available data on bacterial myocarditis was collected before the development of many modern diagnostic tests and before antibiotics. Accordingly, the appropriate workup, diagnosis and treatment remain unclear. Our patient represents the first reported case of ventricular rupture due to methicillin-resistant S. aureus-associated bacterial myocarditis.     

Tako-tsubo cardiomyopathy induced by emotional stress leading to severe mitral regurgitation, cardiogenic shock and cardiopulmonary arrest

Tako-Tsubo cardiomyopathy (TTC) which is usually precipitated by profound emotional and physical stress has been widely reported in the past. In this case we report a young female patient who developed sudden dyspnea and palpitation after an profound stress (fierce argument).The patient had characteristic feature of progressive pulmonary edema. Her symptom worsened gradually leading to cardiopulmonary arrest in a few hours from the onset. After resuscitation an immediately performed echocardiography showed a severe mitral regurgitation due to rupture of antromedial papillary muscle. Left ventricular function showed akinetic mid-to-distal portion of the left ventricular chamber and hyperkinetic in basal segment. Inotrop infusion and aortic balloon pump placement was done because of unstable homodynamics. Semi-elective surgical valve replacement was performed. One year after the acute event the patient remained asymptomatic. Clinicians should recognize that Tako-Tsubo cardiomyopathy is one etiology of acute pulmonary edema with normal coronary artery finding.     

Diagnosis of papillary muscle rupture after acute myocardial infarction by transthoracic and transesophageal echocardiography

The sensitivity of transthoracic echocardiography to visualize the structural abnormality of papillary muscle rupture (PMR) after acute myocardial infarction can be anticipated to average about 50%; therefore, we evaluated five patients exhibiting the condition with both transthoracic and transesophageal echocardiography. The use of the two imaging techniques resulted in the fact that no instance of PMR was missed. Using transthoracic echocardiography in two patients and transesophageal echocardiography in four, the ruptured papillary muscle was visualized directly. Mitral insufficiency as an indirect sign was observed in all patients. In one patient the papillary muscle rupture developed in a mitral valve previously affected by endocarditis. All patients underwent mitral valve replacement and coronary artery bypass grafting. The diagnosis was confirmed at surgery in all patients. Four patients died in hospital, the fifth 5 months later. We recommend that transesophageal echocardiography be performed in patients with suspected PMR if transthoracic echocardiography does not provide an unequivocal diagnosis.     

Rupture of the anterolateral papillary muscle caused by a single diagonal branch obstruction.

This report presents the first case of anterolateral papillary muscle rupture caused by a diagonal branch occlusion only. Although the patient was in shock on admission, he was successfully treated by emergency surgery after hemodynamic stabilization by a percutaneous cardiopulmonary support system. This case implies that the anterolateral papillary muscle has a single blood supply and that it can rupture by an occlusion of only one diagonal branch even after balloon angioplasty.     

Isolated acute anterolateral papillary muscle rupture presenting as a sole manifestation of acute myocardial infarction and mimicking mitral valve vegetation.

We present here a case of an acute myocardial infarction presenting solely as rupture of the head of anterolateral papillary muscle of the mitral valve with an echocardiographic appearance of a mitral valve vegetation. A 61-year-old male patient presented to the hospital with cardiogenic shock. Transesophageal echocardiography revealed normal left ventricular global and regional systolic function with the echocardiographic appearance of a large vegetation attached to the anterior mitral valve leaflet and severe mitral regurgitation. Intraoperatively, an infracted and ruptured head of the anterolateral papillary muscle was found with no evidence of vegetations. Papillary muscle rupture is a rare complication of acute myocardial infarction, is usually associated with inferior myocardial infarction and rarely seen as the only clinical and echocardiographic finding. Transesophageal echocardiography is more sensitive than transthoracic echocardiography but misdiagnosis can still occur.     

Rupture of papillary muscle during dobutamine stress echocardiography

A 72-year-old man presented with an acute myocardial infarction, he did not receive any reperfusion therapy because he presented as a non-ST elevation myocardial infarction (MI). A dobutamine stress echocardiography was done five days after. A partial rupture of the posterior papillary muscle occurred during the stress test. The patient developed cardiogenic shock; he improved after medical management, and mitral repair was done a few days after.     

Left ventricular free wall rupture in acute fulminant myocarditis during long-term cardiopulmonary support

A 77-year-old woman with acute myocarditis developed cardiogenic shock soon after admission and was given mechanical cardiopulmonary support. Echocardiography revealed severe global left ventricular hypokinesia. After 5 days of mechanical support, left ventricular wall motion gradually began to improve, but the patient died of cardiac tamponade on day 13. At necropsy, a free wall rupture was found where the apical akinetic area bordered the basal portion, an area which had shown better wall motion. Left ventricular free wall rupture in acute myocarditis has not been reported, but this case indicates that it may occur in fulminant myocarditis when a cardiopulmonary support system is used.     

Cardiac rupture during stress echocardiography

A case of acute cardiac rupture during dobutamine stress echocardiography testing that was performed on the sixth day after admission for an acute inferoposterior myocardial infarction is reported. Following successful surgical repair, the postoperative course was complicated by severe mitral regurgitation secondary to papillary muscle rupture.