The Rupture of the head of postmedial papillary muscle. Mechanical complications of myocardial infraction with normal angiographic image of coronary vessels.

Abstract

Key words:myocardial infarction, MINOCA, the rapture of the head of postmedial papillary muscle, mechanical complications of myocardial infarction, acute mitral regurge. AbstractMyocardial infarction with non-obstructive coronary arteries (MINOCA) is usually mild in course without any life-threatening complications.This paper presents an atypical case of a 74-year-old patient with myocardial infarction who despite a normal angiography image suffered from complete tear of the head of the posteromedial papillary muscle followed by acute cardiac failure and cardiogenic shock. Case studyA 74-year-old female patient was treated for arterial hypertension, adult-onset diabetes, and paroxysmal atrial fibrillation. After implanting a dual-chamber cardiac pacemaker, as a result of second degree atrioventricular block, she was admitted to the Cardiology Ward with expanded pulmonary edema and low arterial blood pressure. Five days earlier the patient had reported coronary pain in the chest.Following admission the patient's condition was generally severe with dyspnea at rest, which required passive oxygen therapy, but without chest pain.Physical examination showed: arterial blood pressure of 90/60 mm/Hg (in spite of using pressor amines), normal heart rate (60/min), auscultatory loud systolic murmur above the heart apex radiating to the left axillary fossa and scapula, features characteristic for pulmonary congestion (class IV according to Killip and Kimball), blood oxygen saturation 79%, mild swelling of lower legs, normal body temperature. Laboratory investigation indicated highly elevated levels of troponin T, N-terminal-pro B type natriuretic peptide (NT-proBNP) and C reactive protein (CRP). Then, the electrocardiogram showed atrial fibrillation, and left bundle branch block with periodic and effective ventricular pacing. The indicative bedside transthoracic echocardiogram (TTE) presented lowered systolic function of the left ventricle muscle (EF about 40%) with hypokinesis of the inferolateral, inferior, and lateral walls, as well as presence of hemodynamically significant mitral regurgitation due to prolapse of the posterior valve leaflet. As a matter of urgency, the diagnostics were extended to transe-

Apparently Spontaneous Partial Rupture of Anterolateral Papillary Muscle Requiring Urgent Surgery

“…PM rupture is a rare complication of acute myocardial infarction (AMI) with an incidence of 0.05% [1]. The most common cause of PM rupture is myocardial infarction due to atherothrombotic coronary artery disease (more often ST-segment elevation myocardial infarction, less frequently non-ST segment elevation myocardial infarction), other rare etiologies include: myocardial infarction with non-obstructive coronary arteries (MINOCA), trauma, syphilis, periarteritis nodosa, vegetating valvulitis, myocardial abscess, iatrogenic, and cocaine use [2,3]. Mortality can reach the 50 % in first 24 hours and the 80 % in the first week if surgically untreated [4].…”