Surgical treatment for post-infarction papillary muscle rupture: a multicentre study

Abstract

OBJECTIVES Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. METHODS Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. RESULTS A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07–6.45, P = 0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02–15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00–1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16–0.92, P = 0.031). CONCLUSIONS Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. Clinical trial registration clinicaltrials.gov: NCT03848429.

Mitral valve repair in papillary muscle rupture

“…This also allows for height adjustment enabling good coaptation ( 27 observational studies, patients undergoing mitral repair for PMR, annuloplasty rings or bands were used to support the mitral valve from future annular dilatation. The preference for mitral valve repair when compared to mitral valve replacement appeared to be higher in earlier studies reducing to 17% in the most recent case series (13), reflecting surgeons' preference for mitral valve replacement. Mitral valve repair failure rate ranged from 4% to 50% (11,13,14,18,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37).…”

“…The preference for mitral valve repair when compared to mitral valve replacement appeared to be higher in earlier studies reducing to 17% in the most recent case series (13), reflecting surgeons' preference for mitral valve replacement. Mitral valve repair failure rate ranged from 4% to 50% (11,13,14,18,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37). This is likely to be due to a combination of edema, progression of tissue necrosis and lack of tensile strength in the ischemic tissues.…”

“…Chordal sparing mitral valve replacement is more commonly carried out in the setting of acute PMR. Multiple case series have been published with reported in-hospital mortality of 20-25% (13,14). Similarly, 5-and 10-year survival of 65-68% and 32-56%, respectively (15)(16)(17).…”

“…In multiple observational studies, including case series and case reports of patients who developed PMR following an acute MI, the core principles of repair in these patients were largely based on Carpentier's reconstructive valve techniques (11,13,14,18,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37). The different surgical techniques used to repair the mitral valve in these studies included:…”

A Hybrid Intervention for Post-infarction Papillary Muscle Rupture with Severe Mitral Regurgitation: A Case Report

“…While it is important to intervene as early as possible in the treatment of AMR to improve patients’ prognosis [ 4 ], for MR and for revascularization [ 5 ], the treatment of this disease in elderly patients should be as minimally invasive as possible to avoid developing postoperative disuse syndrome. Although increasingly many reports in the literature advocate for transcatheter mitral valve repair (TMVr) as an alternative treatment option for inoperable or high- surgical-risk patients, TMVr is not routinely performed in acute settings [ 4 ].…”