scholarly journals 505 Car accident, an unusual cause of acute severe mitral regurgitation due to anterolateral papillary muscle rupture

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
H El Jattari ◽  
E Snijders ◽  
S Laga ◽  
A Van Berendoncks
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Left Atrium ◽  
Papillary Muscle ◽  
Left Ventricular ◽  
Valve Prosthesis ◽  
Severe Mitral Regurgitation ◽  
Papillary Muscle Rupture ◽  
Muscle Rupture ◽  
Echocardiographic Findings

Abstract A 52-year-old man was admitted to the emergency department of the University Hospital after being involved in a car crash. At first he was alert with stable vital parameters. There was bilateral rales on lung auscultation, without further prominent aberrant findings at the initial clinical examination. Shortly after, he became agitated with respiratory distress, resulting into respiratory insufficiency. Computed tomography (CT) scan of the thorax showed multiple rib fractures, a translated sternal fracture and pulmonary contusion. After intubation and stabilization he was transferred to the Intensive Care Unit (ICU), where his respiratory and cardiovascular parameters progressively worsened, leading to cardiogenic shock. An urgent chest X-ray revealed a tension pneumothorax with mediastinal shift to the right, for which a chest tube was inserted in the left hemithorax. No or little improvement was seen after this intervention. Therefore, an emergency transthoracic echocardiography (TTE) was performed. Subcostal view showed a severe mitral regurgitation with a mass in the left atrium. Because of a limited transthoracic window, we proceeded to a transoesophageal echocardiogram (TEE). A completely ruptured anterolateral papillary muscle of the mitral valve was seen, protruding in the left atrium and resulting in severe mitral regurgitation (Figure). Other echocardiographic findings were a hyperdynamic systolic function of the left ventricle, a hypo-contractile right ventricle with a mild-to-moderate quantity of pericardial effusion. Taking into account the increased cardiovascular risk profile of the patient, a coronary angiography was performed and showed normal coronary anatomy. Consequently, urgent surgical intervention was performed. Perioperative assessment confirmed the earlier described echocardiographic findings. Due to severe laceration of the left ventricular wall at the level of the attachment site of the anterolateral papillary muscle, reconstructive surgery was not possible. The anterolateral papillary muscle head with the attached mitral valve leaflet was fully excised with repair of the concealed myocardial rupture site. A mechanical mitral valve prosthesis and an intra-aortic balloon pump for hemodynamic support were placed. After four days the balloon pump was removed and the tenth day after admission the patient was extubated. Conclusion Acute severe mitral regurgitation due to papillary muscle rupture is a rare but potential fatal complication of a blunt trauma. TOE is essential in early diagnosis. Abstract 505 Figure 1

Abstract 14887: Look Beyond the Coronaries: A Rare Cause of Acute Papillary Muscle Rupture

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Calvin M Kagan ◽  
Benjamin Kenigsberg ◽  
Gaby WEISSMAN ◽  
Mark Hofmeyer ◽  
Samer S Najjar ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Invasive Mechanical Ventilation ◽  
Lv Function ◽  
Papillary Muscle Rupture ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Muscle Rupture

A 63-year-old male with numerous cardiac risk factors presented with two hours of rapidly progressing chest pain and shortness of breath. Exam was notable for respiratory distress requiring non-invasive mechanical ventilation and a holosystolic apical murmur radiating to the axilla. He had an elevated troponin and an electrocardiogram with anteroseptal ST depressions. He was diagnosed with a non-ST segment elevation acute coronary syndrome and taken for cardiac catheterization. Surprisingly, no occlusive epicardial disease was discovered. Left ventriculogram revealed engorgement of the left atrium and pulmonary arteries suggestive of severe mitral regurgitation. The mechanism of mitral regurgitation was unclear until transesophageal echocardiography showed a ruptured posteromedial papillary muscle with flail mitral valve, a picture classically caused by myocardial infarction. Cardiac MRI demonstrated preserved LV function with minor inferior apical hypokinesis, nonspecific endocardial late gadolinium enhancement in the inferior segments, and a small LV thrombus. An embolic myocardial infarction targeting a small territory involving posteromedial papillary muscle was thought most probable. The patient then underwent an uneventful mitral valve replacement and recovery. However, he returned two months later with severe biventricular dysfunction and cardiogenic shock with peripheral eosinophilia. Myocardial biopsy confirmed the diagnosis of eosinophilic myocarditis. An exhaustive workup for the etiology of his eosinophilia proved unrevealing; he was consequently diagnosed with the idiopathic subtype. The case highlights a rare but important clinical entity that has a varied phenotype. Our patient presented atypically with an acute papillary muscle rupture that mimicked an acute myocardial infarction, ultimately delaying diagnosis. As evidenced by our case, clinical suspicion of myocarditis should be high in all patients presenting with typical anginal symptoms with mechanical or circulatory compromise in the absence of acute coronary occlusion.

Mechanical complications of myocardial infarction

2018 ◽  
Author(s):  
José López-Sendón ◽  
Esteban López de Sá
Keyword(s):  
Myocardial Infarction ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Thrombus Formation ◽  
Left Ventricular ◽  
Free Wall ◽  
Papillary Muscle Rupture ◽  
Mechanical Complications ◽  
Muscle Rupture

Mechanical complications after an acute infarction involve different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies occurring in <1% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment (Ibanez et al, 2017). Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.

Results of valve replacement for severe mitral regurgitation due to papillary muscle rupture or fibrosis

1973 ◽  
Vol 32 (3) ◽  
pp. 313-321 ◽  
Author(s):  
D. Luke Glancy ◽  
Edward B. Stinson ◽  
Richard L. Shepherd ◽  
Samuel B. Itscoitz ◽  
William C. Roberts ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Valve Replacement ◽  
Papillary Muscle ◽  
Severe Mitral Regurgitation ◽  
Papillary Muscle Rupture ◽  
Muscle Rupture

Mechanical complications of myocardial infarction

2016 ◽  
Author(s):  
José López-Sendón ◽  
Esteban López de Sá
Keyword(s):  
Myocardial Infarction ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Papillary Muscle ◽  
Thrombus Formation ◽  
Left Ventricular ◽  
Free Wall ◽  
Papillary Muscle Rupture ◽  
Mechanical Complications ◽  
Muscle Rupture

Mechanical complications after an acute infarction include different forms of heart rupture, including free wall rupture, interventricular septal rupture, and papillary muscle rupture. Its incidence decreased dramatically with the widespread use of reperfusion therapies but may occur in 2–3% of ST-elevation myocardial infarction patients, and mortality is very high if not properly diagnosed, as surgery is the only effective treatment. Echocardiography is the most important tool for diagnosis that should be suspected in patients with hypotension, heart failure, or recurrent chest pain. Awareness and well-established protocols are crucial for an early diagnosis. Modern imaging techniques permit a more reliable and direct identification of left ventricular free wall rupture, which is almost impossible to identify with conventional echocardiography. Mitral regurgitation, secondary to papillary muscle ischaemia or necrosis or left ventricular dilatation and remodelling, without papillary muscle rupture, is frequent after myocardial infarction and is considered as an independent risk factor for outcomes. Revascularization to control ischaemia and surgical repair should be considered in all patients with severe or symptomatic mitral regurgitation in the absence of severe left ventricular dysfunction. Other mechanical complications include true aneurysms and thrombus formation in the left ventricle. Again, these complications have decreased with the use of early reperfusion therapies and, for thrombus formation, with aggressive antithrombotic treatment. In a single large randomized trial (STICH), surgical remodelling of the left ventricle failed to demonstrate a significant improvement in outcomes, although it still may be an option in selected patients.

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