Ischemic rupture of the anterolateral papillary muscle

Abstract

We describe the case of a 59-year-old man who presented with chest pain and ST-segment elevation in the inferior leads, R > S in V1 and ST depression in the anterior leads due to proximal occlusion of the first obtuse marginal. Primary coronary angioplasty and stenting of this artery were performed. Twelve hours later the patient became hemodynamically unstable and severe mitral regurgitation due to rupture of one of the heads of the anterolateral papillary muscle was diagnosed. Emergency surgery was performed (papillary muscle head reimplantation, mitral annuloplasty with a rigid ring, tricuspid annuloplasty and coronary artery bypass grafting). On surgical inspection, it was observed that the detached muscle head had become trapped in the left ventricle by a secondary cord attached to the other head.This case is unusual in presenting two uncommon features of ischemic papillary muscle: rupture of the anterolateral muscle in myocardial infarction involving the inferoposterior walls, and the fact that the ruptured muscle head did not prolapse because it had become trapped in the left ventricle by secondary cord attachment. © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L. All rights reserved. PALAVRAS-CHAVEMúsculo papilar; Rutura; Reimplantação cirúrgica; Ecocardiograma Rutura isquémica do músculo papilar ântero-lateralResumo Apresentamos um caso de um homem, de 59 anos de idade, admitido no Serviço de Urgência por dor torácica e elevação ST nas derivações inferiores, r > s em V1 e depressão ST nas derivações precordiais, devido a oclusão da primeira obtusa marginal. Foi realizada angioplastia primária dessa lesão com implantação de stent revestido. Doze horas depois, o doente desenvolve instabilidade hemodinâmica, tendo sido diagnosticada uma insuficiência mitral grave por rutura de uma das cabeças do músculo papilar ântero-lateral. O doente foi submetido a cirurgia emergente (reimplantação do músculo papilar ântero-lateral, anuloplastia mitral com anel rígido, anuloplastia tricúspide e revascularização miocárdica). A inspeção cirúrgica revelou que a cabeça muscular rompida se mantinha presa ao ventrículo esquerdo por uma corda secundária que a ligava à outra cabeça do músculo papilar ântero-lateral.

A New Surgical Repair Technique for Ischemic Total Papillary Muscle Rupture

“…The posteromedial PMs have a single blood supply from the posterior descending artery, whereas the anterolateral PM has a dual blood supply from the LAD and LCX. This difference in blood supply explains why rupture of the posteromedial PM is three to 12 times more likely [1][2][3][4][5]7]. In our patient, it is presumed that the anterolateral PM was ruptured by acute occlusion of the LCX on the condition of severe stenosis of the LAD and the first diagonal branch.…”

“…Emergency surgical intervention is the treatment of choice for this group. Mitral valve replacement is preferred in unstable patients, but several reports suggest that repair offers an improved surgical result by better preserving left ventricular function in selected cases [1][2][3][4][5][6][7]. In this highrisk group, the literature on repair is relatively sparse, particularly regarding patients with complete PM rupture.…”

“…However, in acute postinfarction PM rupture, there is limited experience, and most surgeons prefer replacement over repair. The main reasons for this decision are related to the following disadvantages associated with repair: (1) questionable longterm durability of a repair that inevitably requires suturing onto friable and infarcted myocardial tissues, (2) longer operative duration, (3) greater technical demands for successful repair, and (4) potential of recurrent MR after ventricular remodeling progression [1][2][3][4][5][6][7].…”

Region of Interest analysis using mass spectrometry imaging of mitochondrial and sarcomeric proteins in acute cardiac infarction tissue

“…In such cases, fragmented HBA from erythrocytes may become identifiable in the injured myocytes. Clinically, ischemic rupture of the anterolateral papillary muscle has been frequently reported 27 .…”

Anterolateral papillary muscle rupture caused by myocardial infarction: A case report

“…The preferred treatment for PMR is to replace the mitral valve with a prosthetic valve (MVR). The alternative to MVR is mitral valve repair, which consists of reattachment of the ruptured papillary muscle head to the base of the papillary muscle or to the left ventricle with or without ring annuloplasty [12,13]. Although mitral valve repair can be performed with a good outcome in selected cases [12,13], this technique is technically more challenging, especially in friable infarcted tissue.…”