Abstract We report a case of spontaneous mechanical papillary muscle rupture. In theory, the papillary muscle works as a shock absorber that compensates for geometric changes of left ventricular wall. We believe that the aetiology of papillary muscle rupture, in this case, is linked to the physical and mechanical strains exerted on the papillary. We performed a mitral valve repair with excellent short- and long-term results. Mitral valve repair, Papillary muscle, Mitral valve regurgitation INTRODUCTION Acute mitral regurgitation resulting from papillary muscle rupture (PMR) is a rare life-threatening condition frequently associated with coronary artery disease. When ischaemic disease is absent, the PMR can be as a result of other ischaemic and embolic causes or blunt chest trauma [1, 2]. Here, we present a case of a patient with a spontaneous posteromedial papillary muscle rupture related only to the physical and mechanical strains exerted on the papillary. CASE REPORT We report the case of a 62-year-old woman, with no known history of heart disease nor chest trauma, who presented to her primary care physician with a dry non-productive cough and dyspnoea. Flu syndrome was suspected, but 2 days later, she was admitted to the emergency department with symptoms of respiratory distress and cardiogenic shock. Cardiac enzymes were not elevated. A transthoracic echocardiography showed a severe mitral regurgitation with hypermobile material and a hyperdynamic non-dilated left ventricle. Transoesophageal echocardiography clearly revealed severe eccentric mitral regurgitation with P3 and A3 prolapse, associated with the rupture of the posteromedial papillary muscle. The coronary angiogram showed no coronary lesions (Fig. 1A and B). Figure 1 View largeDownload slide (A and B) Coronary angiography revealed no critical stenosis. (C and D) Intraoperative image of partial posteromedial papillary muscle head rupture. Figure 1 View largeDownload slide (A and B) Coronary angiography revealed no critical stenosis. (C and D) Intraoperative image of partial posteromedial papillary muscle head rupture. Urgent surgery was indicated. The operation revealed a structurally normal mitral valve with partial rupture of the posterior head of the posteromedial papillary muscle (Fig. 1C and D). No signs of endocarditis or inflammatory process were discovered. The head and the base of the ruptured papillary muscle were frail and did not seem to be infarcted, but rather were haemorrhagic (Fig. 2A). Figure 2 View largeDownload slide (A) Intraoperative image of papillary muscle with haemorrhagic tissue without any sign of inflammatory process. (B) Mitral valve repair. Figure 2 View largeDownload slide (A) Intraoperative image of papillary muscle with haemorrhagic tissue without any sign of inflammatory process. (B) Mitral valve repair. In spite of general tissue friability, mitral valve repair was considered. After the head of papillary muscle was unravelled, a reimplantation was performed for the papillary muscle head next to the broken one, using a 4-0 Gore-Tex sutures reinforced with pledgets. Two other 4-0 Gore-Tex neochordae were implanted in A2 and A3 segments of the anterior mitral leaflet as well as a rigid annuloplasty ring to complete the repair (Fig. 2B). The result was excellent, transoesophageal echocardiography showed no regurgitation and recovery was uneventful. At 5-year follow-up, annual echocardiography revealed no evidence of mitral regurgitation. DISCUSSION PMR is a rare but life-threatening condition associated generally with coronary artery disease. In the absence of coronary artery disease, other conditions may explain the infarction of papillary muscle. In our case, the coronary artery angiography was normal, and there was no evidence of ventricular hypertrophy, hypertension or vasculitis that could justify the rupture . No evidence of a hypercoagulable state or infective state was present in our patient. Other potential mechanisms for isolated papillary muscle infarction are blunt trauma and eosinophil-mediated damage, but these mechanisms were also excluded. One possible explanation of spontaneous rupture of the papillary muscle head in our patient, is that it might be linked to the physical and mechanical strains on the papillary. The papillary muscle is actually considered as the active anchoring point of the chordae tendinae to the left ventricle wall, and it works by an independent mechanism as a shock absorber to compensate for geometric changes of left ventricular wall and to maintain the basic mitral valve geometry during the cardiac cycle . These physical and mechanical constraints facilitate the breakdown of chorda tendinea, but when the forces are spread out evenly and in the presence of fragile tissue due to degenerative changes, we believe that a spontaneous mechanical rupture of the papillary itself is possible. This theory is supported by the intraoperative findings and the absence of causes reported in the literature. Once a PMR has been diagnosed, urgent mitral surgery is required to correct the haemodynamic instability of the patient. The standard treatment is valve replacement rather than valve repair. Different features determine the feasibility and durability of repair, such as the type of rupture, whether it is complete or partial, the cause, the adjacent tissue quality, the surgical skill for repair and the ventricular remodelling progression . In our case, although the papillary was extremely frail in the presence of a normal valve, mitral valve repair with reimplantation of the papillary muscle was performed. We believe that mitral valve repair is reliable and provides excellent long-term results, but it must be individualized. CONCLUSION The illustrated case shows a spontaneous mechanical rupture of papillary muscle secondary to the physical and mechanical strains on the papillary. We performed a mitral valve repair with excellent short- and long-term results, but it depends essentially on the adjacent tissue quality, and therefore mitral valve repair must be individualized. Conflict of interest: none declared. REFERENCES 1 Gouda P, Weilovitch L, Kanani R, Har B. Case report and review of nonischemic spontaneous papillary muscle rupture reports between 2000 and 2015. Echocardiography 2017; 34: 786– 90. Google Scholar CrossRef Search ADS PubMed 2 Bruschi G, Agati S, Iorio F, Vitali E. Papillary muscle rupture and pericardial injuries after blunt chest trauma. Eur J Cardiothorac Surg 2001; 20: 200– 2. Google Scholar CrossRef Search ADS PubMed 3 Lazar HL, Bernard SA. Acute anterolateral papillary muscle rupture in the absence of coronary artery disease. J Card Surg 2010; 25: 518– 9. Google Scholar CrossRef Search ADS PubMed 4 Joudinaud TM, Kegel CL, Flecher EM, Weber PA, Lansac E, Hvass U et al. The papillary muscles as shock absorbers of the mitral valve complex. An experimental study. Eur J Cardiothorac Surg 2007; 32: 96– 101. Google Scholar CrossRef Search ADS PubMed 5 Lee SK, Heo W, Min H-K, Kang DK, Jun HJ, Hwang Y-H. A new surgical repair technique for ischemic total papillary muscle rupture. Ann Thorac Surg 2015; 100: 1891– 3. Google Scholar CrossRef Search ADS PubMed © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
European Journal of Cardio-Thoracic Surgery – Oxford University Press
Published: Apr 1, 2018
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