Mitral valve repair for post-myocardial infarction papillary muscle rupture

Abstract

Mitral valve repair for partial or incomplete post-MI PMR is reliable and provides good short- and long-term results, provided established repair techniques are used and adjacent tissue is not friable. PMR type and adjacent tissue quality ultimately determine the feasibility and durability of repair.

Acute Complications of Myocardial Infarction in the Current Era

“…94 There are no randomized studies that compare repair and replacement or different repair techniques for MR due to post-MI PMR. 95 When PMR is complete, repair is not feasible because the tissue is very friable. A segmental prolapse secondary to a partial PMR with limited adjacent tissue damage is often amenable to a reliable repair.…”

Mechanical Complications of Myocardial Infarction

“…Mortality may be as high as 50% in the first 24 h, and up to 80% in the first week, when only medical treatment is applied. Timing of rupture stays in a range between 1 and 14 days, but 80% occurs in 7 days [36].…”

“…PMR is most common with an inferior myocardial infarction, and the posteromedial papillary muscle is most often involved (6 to 12 times more frequently than anterolateral papillary muscle); that's because of its single blood supply through the posterior descending coronary artery (anterolateral papillary has a dual blood supply, instead, from the left anterior descending and left circumflex arteries) [36,37,39].…”

“…Left ventricular function is usually hyperdynamic as a result of ventricular contraction against the low impedance left atrium. Haemodynamic monitoring with a Swan-Ganz catheter can reveal large (> 50 mmHg), early V waves in the pulmonary capillary wedge pressure, and no increase in oxygen saturation from right atrium to right ventriculum (useful to conduct differential diagnosis with septal rupture) [36,37,38]. The only real treatment for papillary muscle rupture is surgery, although it is high risk (operative mortality up to 20-25%) [37].…”

“…A surgical repair of the papillary muscle head is really rare, but possible, with pledgeted sutures and the addition of glue to strengthen the repair. Mitral valve repair rather than replacement should be attempted when there is no papillary muscle necrosis [36,37]. …”