Anterolateral papillary muscle rupture caused by myocardial infarction: A case report
© Jayawardena et al; licensee BioMed Central Ltd. 2008
Received: 14 July 2008
Accepted: 20 September 2008
Published: 20 September 2008
The rupture of the anterolateral papillary muscle is less common than the posteromedial papillary muscle since the anterolateral muscle has dual blood supplies, while the posteromedial papillary muscle has a single blood supply.
We present a case report of a 42 year old male presenting with heart failure being diagnosed to have mitral regurgitation from the partial rupture of the anterolateral papillary muscle due to coronary artery disease. The patient underwent a mitral valve replacement and concomitant coronary artery bypass grafting of the first and the second obtuse marginal arteries.
Acute mitral regurgitation can be precipitated by acute myocardial infarction due to rupture of the anterolateral papillary muscle.
Rupture of a papillary muscle is an uncommon but often fatal complication of acute myocardial infarction (MI) which is responsible for approximately 5% of death after MI . The characteristics of the underlying coronary disease will define the clinical presentation and prognosis, the mortality could be as high as 80% during the first week of post MI . The rupture of the posteromedial papillary muscle is most common seen in about 75% of cases. Posteromedial has a single blood supply from the posterior descending branch of a dominant right coronary artery, and is associated with inferior wall infarctions. The rupture of the anterolateral muscle is less common, occurring in 25% of cases, as it has dual blood supplies: from the first obtuse marginal, originating from the left circumflex; and from the first diagonal branch, originating from the left anterior descending. The rupture of the latter is seen with anterolateral MI [2–4]. Papillary muscle rupture is usually seen in relatively small area infarctions, often with modest coronary disease extent revealed by angiogram .
A 42-year-old Asian man presented to the emergency room with progressively worsening dyspnea over the past five days, now at minimal exertion and occasionally also at rest, associated with productive cough with pinkish sputum for the same period of time. He complained of chest tightness, diaphoresis, orthopnea, paroxysmal nocturnal dyspnea, and decreased effort tolerance for over the same period of time. Past medical history was remarkable for hypertension, hyperlipidemia for ten years, non-compliant with medications, active smoker, and Family history of coronary artery disease, father died of myocardial infarction at the age of fifty-two.
We presented the case of a patient admitted status post-acute myocardial infarction secondary to the occlusion of the first obtuse marginal, with consequent MR as a mechanical complication of the MI and congestive heart failure. When the transesophageal echocardiogram was performed the MR was found to be secondary to the partial rupture of the anterolateral papillary muscle, which could not be appreciated with a transthoracic echocardiogram.
The clinical presentation and severity of a papillary muscle rupture depends on the involved coronary artery and Left ventricular performance. This is usually clinically apparent 6 days post-acute MI , compatible with the presentation of our patient. As stated previously, the anterolateral papillary muscle is less often involved in a rupture than the posterior papillary muscle, because of its dual blood supply.
Different types of lesions to the papillary muscle may occur as a complication of ischemia; prolapse, elongation or rupture in different degrees, partial rupture being the most common type of rupture . The precise diagnosis of papillary muscle rupture can be difficult to establish by transthoracic echocardiography, as the ruptured head may not prolapse into the left atrium, making transesophageal echocardiography a more sensitive and useful tool for diagnosis [6–8].
Due to the high mortality rates with the medical management of papillary muscle rupture impose urgent surgical intervention, the timing of intervention being dictated by the patient's hemodynamic stability [9–12]. The survival rates seem to be related to the extent of papillary muscle rupture, with the best results occurring when a small portion of the tip is ruptured, related to small infarction and limited coronary disease .
This case confirms the importance of an immediate echocardiographic evaluation in establishing the diagnosis, whenever an acute mechanical complication from an acute MI is suspected. The definitive therapy is surgical valve repair  or most often, replacement, which should be undertaken as soon as possible because clinical deterioration in these patients can be sudden.
A written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent will be made available on request.
Left Ventricular Ejection Fraction
Effective Regurgitatant Volume
Proximal Isovelocity Surface Area: OM1: Obtuse Marginal Artery 1
Obtuse Marginal Artery 2
New York Heart Association
- Nishimura RA, Schaff HV, Shub C, Gersh BJ, Edwards WD, Tajik AJ: Papillary muscle rupture complicating acute myocardial infarction: analysis of 17 patients. Am J Cardiol. 1983, 51: 373-377. 10.1016/S0002-9149(83)80067-8.View ArticlePubMedGoogle Scholar
- Voci P, Bilotta F, Caretta Q, Mercanti C, Marino B: Papillary muscle perfusion pattern. A hypothesis for ischemic papillary muscle dysfunction. Circulation. 1995, 91: 1714-1718.View ArticlePubMedGoogle Scholar
- Kim TH, Seung KB, Kim PJ, Baek SH, Chang KY, Shin WS, Choi KB, Moon SW: Images in cardiovascular medicine. Anterolateral papillary muscle rupture complicated by the obstruction of a single diagonal branch. Circulation. 2005, 112: 269-270. 10.1161/CIRCULATIONAHA.104.505016.View ArticleGoogle Scholar
- Wada H, Yasu T, Murata S, Ohta M, Kubo N, Fujii M, Kuroki M, Kawakami M, Saito M: Rupture of the anterolateral papillary muscle caused by a single diagonal branch obstruction. Circ J. 2002, 66: 872-873. 10.1253/circj.66.872.View ArticlePubMedGoogle Scholar
- Jouan J, Tapia M, R CC, Lansac E, Acar C: Ischemic mitral valve prolapse: mechanisms and implications for valve repair. Eur J Cardiothorac Surg. 2004, 26: 1112-1117. 10.1016/j.ejcts.2004.07.049.View ArticlePubMedGoogle Scholar
- Moursi MH, Bhatnagar SK, Vilacosta I, San Roman JA, Espinal MA, Nanda NC: Transesophageal echocardiographic assessment of papillary muscle rupture. Circulation. 1996, 94: 1003-1009.View ArticlePubMedGoogle Scholar
- Assi ER, Tak T: Posterior myocardial infarction complicated by rupture of the posteromedial papillary muscle. J Heart Valve Dis. 1999, 8: 565-566.PubMedGoogle Scholar
- Apetrei E, Rugina M, Iliescu V, Deleanu D, Miclea I, Filipescu D, Chioncel O, Mereuta A: Anterolateral papillary muscle rupture: diagnosis and successful treatment (a case report). Echocardiography. 2002, 19: 143-144. 10.1046/j.1540-8175.2002.00143.x.View ArticlePubMedGoogle Scholar
- Minami H, Mukohara N, Obo H, Yoshida M, Nakagiri K, Hanada T, Maruo A, Matsuhisa H, Morimoto N, Shida T: Papillary muscle rupture following acute myocardial infarction. Jpn J Thorac Cardiovasc Surg. 2004, 52: 367-371.View ArticlePubMedGoogle Scholar
- Defraigne JO, Lavigne JP, Remy D, Dekoster G, Limet R: Mitral valve replacement in post-infarction rupture of the papillary muscle. Apropos of 13 cases surgically treated during the acute phase of infarction. Arch Mal Coeur Vaiss. 1990, 83: 377-382.PubMedGoogle Scholar
- Nunley DL, Starr A: Papillary muscle rupture complicating acute myocardial infarction. Treatment with mitral valve replacement and coronary bypass surgery. Am J Surg. 1983, 145: 574-577. 10.1016/0002-9610(83)90094-6.View ArticlePubMedGoogle Scholar
- 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, 11: 20-25.PubMedGoogle Scholar
- Clements SD, Story WE, Hurst JW, Craver JM, Jones EL: Ruptured papillary muscle, a complication of myocardial infarction: clinical presentation, diagnosis, and treatment. Clin Cardiol. 1985, 8: 93-103.View ArticlePubMedGoogle Scholar
- Fasol R, Lakew F, Wetter S: Mitral repair in patients with a ruptured papillary muscle. Am Heart J. 2000, 139: 549-554. 10.1016/S0002-8703(00)90101-7.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.