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

Abstract

Summary:The sensitivity of transthoracic echocardiography to visualize the structural abnormality of papillary muscle rup ture (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.Key words: papillary muscle rupture, myocardial infarction, echocardiography, transesophageal echocardiography IntmductionThe incidence of papillary muscle rupture (PMR) in acute myocardial infarction is found to be 0.9%,' and averages up to 5% in fatal myocardial infarctions? This complication can de-*This paper contains parts of the doctoral thesis of Guido Dohmen.

Isolated Acute Anterolateral Papillary Muscle Rupture Presenting as a Sole Manifestation of Acute Myocardial Infarction and Mimicking Mitral Valve Vegetation

“…TEE is superior to TTE in this regard. In a review of the literature, Zotz et al [8]reported a sensitivity of 52% for TTE versus 92% for TEE. In our case, transthoracic images were not helpful in making the diagnosis.…”

Role of echocardiography in acute myocardial infarction

“…In the presence of pulmonary edema and shock, the unexpected fi ndings of a hyperdynamic LV, small infarction, or increased early mitral infl ow velocity should prompt a careful search for severe mitral regurgitation, even in the absence of any discernible color regurgitant fl ow. If there is any doubt regarding diagnosis, transesophageal echocardiography should be performed because it is superior in identifying the underlying mechanism of mitral regurgitation [11].…”

The Role of Echocardiography in Acute Myocardial Infarction

“…The superior resolution provided by transesophageal echocardiography can diagnose and define the anatomic abnormality and grade the severity of regurgitation when surface imaging is inconclusive [5,8,10,46]. The posteromedial papillary muscle is more commonly affected than the anterolateral because of its singular blood supply.…”