Abstract Papillary muscle rupture is a rare complication after myocardial infarction. Almost all cases occur in the papillary muscle of the mitral valve. The development of tricuspid regurgitation after right ventricular myocardial infarction caused by papillary muscle rupture is extremely rare. We present a 70-year-old man with massive tricuspid regurgitation caused by papillary muscle rupture after percutaneous coronary intervention to the right coronary artery involving a stent. We performed tricuspid valve repair with a reimplanted papillary muscle in situ using neither artificial chordae nor a prosthetic valve. Previous case reports on this surgical repair technique are not available. Tricuspid papillary muscle rupture, Tricuspid valve repair, Myocardial infarction INTRODUCTION Papillary muscle rupture (PMR) is a fairly rare, but often fatal, complication after myocardial infarction (MI). Almost all cases occur on the left ventricular side of the papillary muscle in the mitral valve. PMR of the tricuspid valve (TV) after MI is an extremely rare complication. We performed surgical treatment for severe tricuspid regurgitation (TR) caused by PMR after MI. REPORT A 70-year-old man underwent a successful percutaneous coronary intervention for a 90% occlusion of the right coronary artery (Fig. 1A). However, the side branches of the right coronary artery were occluded by the stent implantation (Fig. 1B). Subsequent cardiac magnetic resonance imaging at 2 weeks post-percutaneous coronary intervention showed good left ventricular ejection fraction (60%), no ischaemic findings and no insufficiency in either the TV or the mitral valve. Three months later, he was admitted to our hospital with dyspnoea on exertion and fatigue. He had no pre-existing valvular heart disease, evidence of endocarditis or chest trauma. Transthoracic echocardiography revealed massive TR caused by anterior leaflet prolapse with hypokinesis of the entire right ventricular wall, even though left ventricular ejection fraction was normal (64%) without mitral valve insufficiency (Fig. 1C and D, Video 1). On the basis of these findings, we planned a surgical repair of the TV. The anterior papillary muscle was found to be ruptured, resulting in the anterior tricuspid leaflet prolapse (Fig. 2A, Video 2). We trimmed the end of the ruptured papillary muscle and reattached it to the papillary muscle head using a pledgeted 5-0 Prolene suture and performed an additional ring annuloplasty. An ink test confirmed that an adequate anterior leaflet surface beyond the marked line was available for coaptation. After the operation, echocardiography showed only trivial TR and no significant TV stenosis. Pathological examination of the ruptured papillary muscle revealed necrotic muscle, compatible with an inflammatory phase of MI (Fig. 2B). The predischarge echocardiography also indicated mild TR and no sign of TV stenosis (peak velocity, 1.1 m/s and mean pressure gradient 2 mmHg). Video 1 Preoperative transthoracic echocardiography. Video 1 Preoperative transthoracic echocardiography. Close Video 2 Operative procedure for tricuspid papillary muscle rupture. Video 2 Operative procedure for tricuspid papillary muscle rupture. Close Figure 1: View largeDownload slide (A) Coronary angiography showing a 90% occlusion of the proximal right coronary artery and (B) occluded side branches (arrow heads) after the coronary stent implantation. (C and D) Transthoracic echocardiography revealing the tricuspid anterior leaflet prolapse caused by complete rupture of the papillary muscle (arrow) and severe tricuspid regurgitation. RA: right atrium; RV: right ventricle. Figure 1: View largeDownload slide (A) Coronary angiography showing a 90% occlusion of the proximal right coronary artery and (B) occluded side branches (arrow heads) after the coronary stent implantation. (C and D) Transthoracic echocardiography revealing the tricuspid anterior leaflet prolapse caused by complete rupture of the papillary muscle (arrow) and severe tricuspid regurgitation. RA: right atrium; RV: right ventricle. Figure 2: View largeDownload slide (A) Intraoperative image showing papillary muscle rupture of the tricuspid anterior leaflet. (B) Pathological examination of the end of the ruptured papillary muscle showing neutrophil invasion without fibrosis, indicative of the inflammatory phase of myocardial infarction. Figure 2: View largeDownload slide (A) Intraoperative image showing papillary muscle rupture of the tricuspid anterior leaflet. (B) Pathological examination of the end of the ruptured papillary muscle showing neutrophil invasion without fibrosis, indicative of the inflammatory phase of myocardial infarction. DISCUSSION Almost all cases of PMR occur in the left ventricle. The tricuspid PMR is comparatively rare. In addition to ischaemia, more common causes of tricuspid PMR include endocarditis, myxomatous degeneration and trauma. Only 2 previous case reports on tricuspid PMR after MI are available [1, 2]. Surgical valve repair was not performed in either of them. In the setting of occlusion of the right coronary artery leading to inferior MI, the right ventricular involvement and concomitant severe TR, tricuspid PMR may occur, as described in this case. PMR occurs most frequently within 2–7 days after MI. Our patient experienced the MI for more than 2 weeks prior to PMR. This is because blood pressure on the right side of the heart is lower than on the left side. The rupture of the mitral posteromedial papillary muscle occurs much more frequently than the rupture of the anterolateral muscle. The posteromedial muscle receives blood from only the posterior descending artery, whereas the anterolateral muscle receives a dual blood supply from both the left anterior descending and the left circumflex arteries. Given the singular blood supply to the posteromedial muscle, approximately half of rupture cases occur with relatively small infarcts . The tricuspid muscle set is composed of anterior, posterior and septal papillary muscles attached to the anterolateral ventricular wall, inferior portion of the septum and infundibular septal wall, respectively . In this case, the ruptured tricuspid anterior papillary muscle may have received a singular blood supply from the right coronary artery. Artificial chordae may be applicable for the treatment of TR. In our patient, we performed papillary muscle reimplantation in situ with ring annuloplasty without artificial chordae for TV repair. We believe that this procedure is an excellent option for treating a prolapsed TV leaflet. This is the first case report on surgical TV repair of tricuspid PMR after MI in a patient. However, clinicians should remain aware and be able to diagnose this potential complication in not only the mitral valve but also the TV. Conflict of interest: none declared. REFERENCES 1 Eisenberg S , Suyemoto J. Rupture of a papillary muscle of the tricuspid valve following acute myocardial infarction . Circulation 1964 ; 30 : 588 – 91 . Google Scholar CrossRef Search ADS PubMed 2 Walker JR , Mousavi N , Horlick E , Seifer C , Jassal DS. Tricuspid valvular papillary muscle rupture with intractable hypoxia: a rare complication post MI . J Am Soc Echocardiogr 2009 ; 22 : 863.e1. Google Scholar CrossRef Search ADS 3 Antman EM , Morrow DA. Braunwald’s Heart Disease—A Textbook of Cardiovascular Medicine, 9th edn . Chapter 55—ST-segment elevation myocardial infarction: management . Bonow RO : Saunders, Philadelphia , 2011 , 1150. 4 Nigri GR , Di Dio LJA , Baptista CAC. Papillary muscles and tendinous cords of the right ventricle of the human heart . Surg Radiol Anat 2001 ; 23 : 45 – 9 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Journal of Cardio-Thoracic Surgery – Oxford University Press
Published: May 3, 2018
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