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.     

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.     

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.     

Myocardial rupture following acute myocardial infarction

Ten patients, eight males and two females, suffered myocardial rupture following acute myocardial infarction and required surgery. There were five ventricular septal ruptures, four papillary muscle ruptures and one free wall rupture. Ventricular septal rupture was suspected clinically by the appearance of a new systolic murmur, usually associated with a thrill at the left sternal border. A left to right shunt was confirmed by bedside oximetry using a Swan-Ganz catheter. The mean pulmonary to systemic flow ratio was 3.04:1. Following cardiac catheterization all patients underwent corrective surgery with or without aortocoronary bypass grafting. Three patients with inferior wall myocardial infarction died. Papillary muscle rupture was suspected clinically following the abrupt onset of hypotension with severe acute pulmonary edema accompanied by a new systolic murmur. The diagnosis was confirmed by cardiac catheterization. All underwent surgery for mitral valve replacement with or without aortocoronary bypass grafting. One patient died postoperatively of multiorgan failure. Free wall rupture was suspected clinically by the sudden onset of loss of consciousness, apnea, junctional bradycardia and severe hypotension leading to electromechanical dissociation. The diagnosis was confirmed by demonstrating a significant pericardial effusion by two dimensional echocardiography. Immediate surgery was performed. This patient is totally asymptomatic on no drug treatment six months following discharge. Ten patients underwent emergency surgery for myocardial rupture. Operative mortality was 40%. Patients with ventricular septal rupture associated with an inferior myocardial infarction had a poor prognosis.     

Posterior myocardial infarction complicated by rupture of the posteromedial papillary muscle.

A 61-year-old man was admitted with acute posterior myocardial infarction and, on physical examination, was shown to have a mitral regurgitation (MR) murmur. Transthoracic echocardiography (TTE) showed severe hypokinesis of the posterior wall and severe MR by color flow. Right heart catheterization with a balloon-tipped catheter revealed a pulmonary artery wedge pressure of 30 mmHg. No 'step-up' was seen in blood samples from the right atrium and right ventricle. On angiography, a subtotal occlusion of the mid circumflex artery was found which was angioplastied and stented. As the patient's clinical condition did not improve, he underwent transesophageal echocardiography (TEE) for further evaluation. This showed complete rupture of the posteromedial papillary muscle. The patient underwent urgent surgery with successful mitral valve replacement. The postoperative course was uncomplicated, and clinical improvement seen. This case report underscores the value of TEE in accurate preoperative diagnosis of papillary muscle rupture by providing preoperative anatomic details of the mitral valve apparatus and surrounding structures.     

Pitfalls in the diagnosis and management of papillary muscle rupture: A study of four cases and review of the literature

Four cases of papillary muscle rupture occurring in the setting of acute myocardial infarction are presented, which illustrate the following points: the diagnosis may not be apparent at presentation, a mitral regurgitant murmur may be absent, transesophageal echocardiography may establish the diagnosis when transthoracic echocardiography does not, and appropriate surgical correction can lead to excellent functional recovery.     

Transesophageal echocardiography for detection of mitral regurgitation due to papillary muscle rupture or dysfunction associated with acute myocardial infarction: a report of five cases

Severe mitral regurgitation was associated with cardiogenic shock in five (0.8%) of 623 patients with acute myocardial infarction who were urgently admitted to the authors' hospitals between 1994 and 1996. The infarct was located in the inferior wall in four patients and in the inferoposterior wall in one patient. Severe mitral valve regurgitation occurred concurrently with cardiogenic shock between one and six days after the onset of myocardial infarction. A mitral regurgitant murmur was not audible in four of five patients. Similarly, mitral regurgitant Doppler signals were not detected in four patients by transthoracic echocardiographic examination, while transesophageal echocardiographic examination detected mitral regurgitant signals clearly in all patients. Thus, when cardiogenic shock is unexpectedly associated with inferior or inferoposterior wall acute myocardial infarction, severe mitral regurgitation should be suspected, even when a mitral regurgitant murmur is not audible. Furthermore, mitral regurgitant flow signals may not always be detected by transthoracic echocardiography. Thus, examination for mitral regurgitation by transesophageal echocardiography should be considered.     

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.     

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.     

Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction

Fifty consecutive patients with a newly acquired systolic murmur and severe cardiac decompensation following a recent myocardial infarction (27 with an anterior and 23 with an inferior infarct) were studied by a combination of two-dimensional echocardiography, spectral Doppler and Doppler color flow mapping. The initial ultrasound study defined a ventricular septal rupture in 43 patients and severe isolated mitral regurgitation in 7 patients (5 with papillary muscle rupture and 2 with severe papillary muscle dysfunction). All 50 patients had subsequent confirmation of the diagnosis by either cardiac catheterization or surgical inspection, or both. Two-dimensional echocardiography alone directly visualized a septal defect in only 17 (40%) of the 43 patients with ventricular septal rupture. In all 43 patients the mitral valve appeared normal on imaging. In six of the seven patients with isolated mitral regurgitation, two-dimensional echocardiography correctly demonstrated the structural abnormality of the mitral valve (five with flail anterior leaflet and one with posterior leaflet prolapse). The addition of Doppler color flow mapping greatly improved the diagnostic information in both patient groups. In all 43 patients with ventricular septal rupture, Doppler color flow mapping demonstrated both an area of turbulent transseptal flow and a diagnostic systolic flow disturbance within the right ventricle. In the seven patients with isolated papillary muscle rupture or dysfunction, Doppler color flow mapping not only demonstrated the presence of mitral regurgitation in all cases, but also identified the specific mitral leaflet abnormality by defining the direction of the regurgitant jet.(ABSTRACT TRUNCATED AT 250 WORDS)     

Papillary muscle dysfunction in acute myocardial infarct: a clinical and Doppler echocardiographic study

The "papillary muscle dysfunction" concept includes a disrupted sequence of one or more structures of the mitral valve complex and not merely a disturbance of a papillary muscle itself. We studied a group of seventeen patients, 14 men and 3 women (mean age 51 and 39 years, respectively). Acute myocardial infarction was the first evidence of heart disease. In all of them, Doppler and M mode echocardiography were performed and correlation clinical features were done. In addition a tricuspid regurgitation flow patterns was scanned on each patient. Mitral regurgitation was found in 29% of them by Doppler echocardiography and only 17% had a mitral systolic murmur suggestive of this entity. In those patients with mitral regurgitation-flow patterns, the infarct site was similar to those with anterior and inferior infarction and serum CPK-level was greater in these patients than the non-mitral regurgitation flow pattern group. The evidence of tricuspid regurgitation by pulsed-Doppler echocardiography was associated with mitral regurgitation in 80% of patients, mainly those with right ventricular extension of acute myocardial infarction, and with the greatest hemodynamic impairment. It seems likely in this study, that mitral regurgitation was due to valve ring dilation with an increase of left ventricular diameter and a decrease on ventricular systolic function.     

Papillary muscle rupture in fatal acute myocardial infarction: a potentially treatable form of cardiogenic shock.

Although cardiogenic shock in acute myocardial infarction is usually associated with a critical loss of myocardium, this may not be the case in papillary muscle rupture. During the past 21 years, 13 patients came to autopsy (11 died in cardiogenic shock) with a papillary muscle rupture complicating myocardial infarction. Rupture occurred from 2 to 7 (mean, 4) days after the infarct, and survival after rupture was usually brief (median, 3 days). The infarct involved between 1% and 50% (mean, 19%) of the left ventricle, and in 10 it was less than 25%. In all instances myocardium around the mitral annulus was not infarcted. Because papillary muscle rupture occurred mostly with first infarcts (eight), involved relatively small areas of necrosis, and spared the myocardium surrounding the annulus, early mitral valve replacement should make this cause of fatal acute myocardial infarction one of the most treatable forms of cardiogenic shock.     

Abnormal mitral valve motion associated with ventricular septal defect following acute myocardial infarction.

It is often difficult to make the clinical distinction between acute mitral regurgitation caused by papillary muscle dysfunction or rupture and ventricular septal defect complicating an acute myocardial infarction. A case of a patient with rapidly progressive congestive heart failure and a loud murmur is presented. Echocardiography strongly suggested the presence of a flail posterior mitral leaflet. However, the patient was subsequently found to have rupture of the interventricular septum. This diagnosis was made with bedside right heart catheterization and was later confirmed by left ventriculography and direct inspection at the time of surgery. The mitral valve apparatus was completely normal. Thus this case demonstrates the apparent lack of specificity of the accepted echocardiographic criteria for flail mitral leaflet and acutely ruptured interventricular septum, and the potential necessity of cardiac catheterization to distinguish between these entities.     

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.     

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.     

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.     

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.     

The vital role of papillary muscles in mitral and ventricular function: echocardiographic insights

The two left ventricular (LV) papillary muscles are small structures but are vital to mitral valve competence. Partial or complete rupture, complicating acute myocardial infarction, causes severe or even catastrophic mitral regurgitation, potentially correctable by surgery. Papillary muscle dysfunction is a controversial topic in that the role of the papillary muscle itself, in causing mitral regurgitation post infarction, has been seriously questioned; it is less confusing if this syndrome is attributed not only to papillary muscle but also to adjacent LV wall ischemia or infarction. Papillary muscle calcification is easily and frequently detected on echocardiography, but its clinical significance remains uncertain. Papillary muscle hypertrophy accompanies LV hypertrophy of varied etiology and may have a significant role in producing dynamic late-systolic intra-LV obstruction in hypertrophic cardiomyopathy and other hyperdynamic hypertrophied LV chambers. All the above abnormalities can be adequately assessed by 2-D echocardiography and the Doppler modalities. In selected cases, transesophageal echocardiography can provide additional valuable data by improving visualization of papillary muscles and mitral apparatus.     

Cardiac pseudoaneurysm coupled with a rupture of the papillary muscle complicating myocardial infarction

As a complication of myocardial infarction, dual rupture of the left ventricular myocardium and the papillary muscle is a rare condition. In such a case, the heart is predisposed to reduced output because of unloading of the ventricle during systole, resulting in the patient being in danger of deteriorating into a severe state or dying suddenly from cardiogenic shock. We report a rescued case of a 65-year-old woman, who had cardiogenic shock due to left ventricular pseudoaneurysm, coupled with partial rupture of the posteromedial papillary muscle three weeks after posterior myocardial infarction. Emergent left ventriculography revealed a large aneurysmal cavity and regurgitation towards the left atrium. The patient underwent emergent aneurysmectomy with mitral valve replacement.     

Acute mitral regurgitation caused by infarction-related papillary muscle rupture with successful surgical treatment: case report

We present a case of severe complication of myocardial infarction -- acute mitral regurgitation caused by papillary muscle rupture. A 69-year-old man was admitted with chest pain lasting 1 hour and pulmonary oedema. ECG revealed ST-segment depression in leads II, III, aVF, V2-V6. Soon after admission the patient experienced respiratory disorders and consequently arrest. The patient was transferred in shock to the Department of Cardiothoracic Surgery, where he underwent successful artificial mitral valve implantation. One year later the patient is in good condition (NYHA class I) and the valve is fully functional.