ANSWER:

Posteromedial papillary muscle head (partial) rupture following acute posterior myocardial infarction.

• Papillary muscle rupture is a rare complication of acute myocardial infarction, <1%.
• Posteromedial papillary muscle rupture is associated with inferior or posterior MI and is more common than anterolateral papillary muscle rupture.
• Complete transection of a left ventricular papillary muscle is incompatable with life.
• Not neccessary associate with large MI, about 50%.
• Systolic murmur may be inaudible when blood pressure is low. If (new) systolic murmur is audible, it should be differentiated from ventricular septal rupture. This should be accomplished with echocardiographic study (TTE and TEE).
• TTE should recognize severe mitral regurgitation, but identification of the ruptured papillary muscle as the cause of severe mitral regurgitation will need TEE study.
• Papillary muscle rupture requires quick diagnosis, cardiac catheterization and IABP. Then emergency surgery.

(For more information on the case, please contact Drs. Ed Johnson and Dan Tiede.)

 

 

CURRENT REFERENCES

PAPILLARY MUSCLE RUPTURE FOLLOWING ACUTE MYOCARDIAL INFARCTION

Nishimura RA, Gersh BJ, Schaff HV.
The case for an aggressive surgical approach to papillary muscle rupture following myocardial infarction: "From paradise lost to paradise regained".
Heart. 2000 Jun;83(6):611-3. No abstract available.

Assi ER, Tak T.
Posterior myocardial infarction complicated by rupture of the posteromedial papillary muscle.
J Heart Valve Dis. 1999 Sep;8(5):565-6.

Figueras J, Cortadellas J, Calvo F, Soler-Soler J.
Relevance of delayed hospital admission on development of cardiac rupture during acute myocardial infarction: study in 225 patients with free wall, septal or papillary muscle rupture.
J Am Coll Cardiol. 1998 Jul;32(1):135-9.

Reeder GS.
Identification and treatment of complications of myocardial infarction.
Mayo Clin Proc. 1995 Sep;70(9):880-4. Review.

Samman B, Korr KS, Katz AS, Parisi AF.
Pitfalls in the diagnosis and management of papillary muscle rupture: a study of four cases and review of the literature.
Clin Cardiol. 1995 Oct;18(10):591-6. Review.

SURGICAL TREATMENT

Chen Q, Darlymple-Hay MJ, Alexiou C, Ohri SK, Haw MP, Livesey SA, Monro JL.
Mitral valve surgery for acute papillary muscle rupture following myocardial infarction.
J Heart Valve Dis. 2002 Jan;11(1):27-31.

Tavakoli R, Weber A, Vogt P, Brunner HP, Pretre R, Turina M.
Surgical management of acute mitral valve regurgitation due to post-infarction papillary muscle rupture.
J Heart Valve Dis. 2002 Jan;11(1):20-5; discussion 26.

Fasol R, Lakew F, Wetter S.
Mitral repair in patients with a ruptured papillary muscle.
Am Heart J. 2000 Mar;139(3):549-54.

Yamanishi H, Izumoto H, Kitahara H, Kamata J, Tasai K, Kawazoe K.
Clinical experiences of surgical repair for mitral regurgitation secondary to papillary muscle rupture complicating acute myocardial infarction.
Ann Thorac Cardiovasc Surg. 1998 Apr;4(2):83-6.

ECHOCARDIOGRAM

Iwasaki K, Matsuo N, Hina K, Murakami T, Murakami M, Matano S, Yamaji H, Hamamoto H, Ueeda M, Kusachi S.
Transesophageal echocardiography for detection of mitral regurgitation due to papillary muscle rupture or dysfunction associated with acute myocardial infarction: a report of five cases.
Can J Cardiol. 2000 Oct;16(10):1273-7.

Shaikh N, Rehman NU, Grodman RS.
Posteromedial Papillary Muscle Rupture Associated with Inferoposterior Wall Myocardial Infarction.
Echocardiography. 1999 Apr;16(3):269-270.

Hanlon JT, Combs DT.
Transesophageal echocardiographic assessment of papillary muscle rupture.
Circulation. 1997 Oct 21;96(8):2737-8. No abstract available.

Cramer MJ, Bredero AC, Jaarsma W.
Transesophageal echocardiographic assessment of papillary muscle rupture.
Circulation. 1997 Oct 21;96(8):2737; discussion 2738. No abstract available.

Moursi MH, Bhatnagar SK, Vilacosta I, San Roman JA, Espinal MA, Nanda NC.
Transesophageal echocardiographic assessment of papillary muscle rupture.
Circulation. 1996 Sep 1;94(5):1003-9.

Christ G, Siostrzonek P, Maurer G, Baumgartner H.
Partial papillary muscle rupture complicating acute myocardial infarction. diagnosis by multiplane transoesophageal echocardiography.
Eur Heart J. 1995 Nov;16(11):1736-8.

Herrera CJ, Gurevicius J, Stecy P, Dahodwala M, Tummala A, Nemickas R.
The clinical utility of transesophageal echocardiography in ischemic papillary muscle rupture.
Am J Card Imaging. 1995 Jul;9(3):226-8.

Manning WJ, Waksmonski CA, Boyle NG.
Papillary muscle rupture complicating inferior myocardial infarction: identification with transesophageal echocardiography.
Am Heart J. 1995 Jan;129(1):191-3. No abstract available.

Singh A, Breisblatt W, Cutrone M, Fein S, Ferraris V.
Transesophageal echocardiography as an important tool in the diagnosis of postinfarction papillary muscle rupture.
Cardiology. 1995;86(5):417-20.