Mitral valve surgery for ischemic papillary muscle rupture: outcomes from the Japan cardiovascular surgery database

Abstract

Background Ischemic papillary muscle rupture (PMR) is a catastrophic complication following acute myocardial infarction (AMI). We evaluated early outcomes of PMR by using data from the Japan Cardiovascular Surgery Database, a nationwide Japanese registry. Methods We retrospectively analyzed data from 196 patients diagnosed with PMR following AMI in Japan between January 2014 and December 2017. Risk factors for operative mortality and severe complications following mitral valve surgery were analyzed. Results The 30-day and hospital mortality rates were 20% and 26%, respectively. Chronic hemodialysis, abrupt rupture after AMI, resuscitation before surgery, and preoperative venoarterial extracorporeal membrane oxygenation were associated with mortality. Mitral valve replacement was chosen mainly (90%) for surgical correction of mitral regurgitation in these patients. There was no significant difference in short-term outcomes between mitral valve replacement versus mitral valve repair, despite non-matched characteristics in background between the treatment groups. Concomitant coronary artery bypass grafting had no impact on short-term outcomes. Conclusions Information derived from the nationwide database of patients with AMI-associated PMR show that PMR is a rare condition in the modern era. However, PMR is a severe disease with a mortality rate as high as 26%. The severity of the condition is associated with the risk for poor outcomes. Electronic supplementary material The online version of this article (10.1007/s11748-020-01418-y) contains supplementary material, which is available to authorized users.

Mitral valve repair in papillary muscle rupture

“…This is likely to be due to a combination of edema, progression of tissue necrosis and lack of tensile strength in the ischemic tissues. Over the last three decades, apart from a reduction in the incidence of PMR to 0.07% from 1% to 5% as reported in the case series by Pahuja et al (37), there has not been a significant improvement in surgical in-hospital mortality which has largely remained in the region of 25% (11,13,14,18,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37). This is unsurprising as the conduct of the surgery and mechanical circulatory support has largely remained unchanged.…”

“…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:…”

“…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.…”

Mechanical Complications of Myocardial Infarction

“…Although the incidence of MCs has decreased due to the development of optimal medical therapies and reperfusion therapy, associated mortality rates have remained high. Several studies from Western countries [1][2][3][4][5] and Japan [6][7][8][9][10] have shown the MCs complicating MI in this era of percutaneous coronary intervention (PCI), but most of these studies only indicated the descriptive results of its incidence, treatment, and poor outcomes. In the superaged society in Japan, the proportion of older patients with MI is dramatically increasing.…”