Clinical and echocardiographic presentation of postmyocardial infarction papillary muscle rupture

Abstract

Background Severe mitral regurgitation (MR) can occur following myocardial infarction (MI) with either partial or complete papillary muscle rupture (pPMR or cPMR). Although the incidence of this complication has significantly decreased, it is still associated with significant mortality. We sought to evaluate the different echocardiographic and clinical presentations of pPMR and cPMR. Methods and Results A review of all the urgent procedures for ischemic MR between January 2000 and June 2016 was performed to identify patients who underwent surgery for PMR. Surgical protocols and echocardiographic studies were used to identify patients with cPMR and pPMR. A total of 37 patients had cardiac surgery for PMR (18 cPMR, 19 pPMR). All patients with cPMR were in cardiogenic shock at the time of diagnosis, as opposed to only 53% of patients with pPMR (P = 0.0008). Between the time of diagnosis and surgery, 7 patients with pPMR developed cardiogenic shock. Transthoracic echocardiography (TTE) led to the diagnosis in 72% of cPMR and 32% of pPMR (P = 0.02). TEE had a yield of 100% for both cPMR and pPMR. Six pathologic varieties of post‐MI PMR were recognized on echocardiography and during surgery. Early postoperative, 1 (72% vs 84%), 3 (67% vs 84%), and 5 years (67% vs 74%) survival rates were similar for cPMR and pPMR (P = 0.26). Conclusions Partial PMR is associated with a different clinical and echocardiographic presentation than cPMR. Still, most pPMR patients progress toward cardiogenic shock. Prompt diagnosis and referral for surgery are critical and could potentially decrease mortality.

Blood group A: a risk factor for heart rupture after acute myocardial infarction

“…VSR was characterized by: (1) abnormal physical examination findings such as cardiac systolic murmur and cardiac tremor; (2) Ventricular septal discontinuity can be seen on echocardiography [ 21 ]. The diagnostic criteria of PMR were as follows: (1) abnormal physical examination findings such as new systolic murmur; (2) Echocardiography shows a mobile mass in either the left atrium or ventricle; (3) flail or ruptured chordae with an abnormal-looking papillary muscle [ 9 ].…”

“…VSR happened in approximately 1–3% AMI population before the reperfusion time, with 45% and 90% death rates each for surgical and conservative treatment [ 6 – 8 ]. PMR often causes mitral regurgitation (MR) and present in < 1% of AMI patients who undergo early revascularization according to recent data [ 9 ]. Several previous studies have verified the association between blood group A and the increased risk of vascular diseases including coronary artery disease (CAD) [ 10 – 15 ].…”

Surgical management for mechanical complications of acute myocardial infarction: a systematic review of long-term outcomes

“…Our search identified four original studies with long-term outcomes data for surgical management of postinfarction PMR (Table 3) (42)(43)(44)(45). Operative mortality in the studies ranged from 0 to 19%.…”

Pathophysiology, Diagnosis, and New Therapeutic Approaches for Ischemic Mitral Regurgitation

“…Imbalance between these opposing forces leads to the apical displacement of mitral coaptation, incomplete valve closure, and MR. Ischemic MR can be seen across the spectrum of ischemic heart disease: transient MR during exercise (baseline normal LV function), 2 MR associated with hibernating myocardium, and MR developing after myocardial infarction (MI). Although in some cases acute MI can lead to papillary muscle rupture and acute MR, 3 the present review focuses on the most common scenario of post-MI LV remodelling leading to papillary muscle displacement, leaflet tethering, and subacute or chronic MR. 4 While ischemic LV damage causing MR is most often localised in the posterior LV wall, it can also be global or apical. 5 The location and distribution of LV anomalies will determine the mitral tethering pattern (symmetric or asymmetric) and regurgitant jet orientation.…”