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This article discusses a case of papillary muscle rupture (PMR) in a 61-year-old man who was admitted with acute inferior ST-segment elevation myocardial infarction. The patient underwent coronary angiography, which revealed occlusion of multiple coronary arteries. After a stent was deployed, the patient experienced acute shortness of breath, prompting further testing with transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). The TEE confirmed the diagnosis of PMR, and emergency surgical intervention was performed. Unfortunately, the patient died after surgery. The article emphasizes the importance of TEE in diagnosing PMR when TTE is inadequate. [Extracted from the article]

Purpose of Review: Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography. Recent Findings: The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. Summary: A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention. [ABSTRACT FROM AUTHOR]

Abstract Aims Acute mitral regurgitation (MR) in the setting of myocardial infarction (MI) may be the result of papillary muscle rupture (PMR). This condition is associated with high morbidity and mortality. We aim to evaluate the feasibility of transcatheter edge‐to‐edge mitral valve repair (TEER) in this acute setting. Methods and results We analysed data from the International Registry of MitraClip in Acute Mitral Regurgitation following acute Myocardial Infarction (IREMMI) of 30 centres in Europe, North America, and the middle east. We included patients with post‐MI PMR treated with TEER as a salvage procedure, and we evaluated immediate and 30‐day outcomes. Twenty‐three patients were included in this analysis (9 patients suffered complete papillary muscle rupture, 9 partial and 5 chordal rupture). The patients' mean age was 68 ± 14 years. Patients were at high surgical risk with median EuroSCORE II 27% (IQR 16, 28) and 20 out of 23 (87% were in cardiogenic shock). All patients were treated with vasopressors, and 17 out of 23 patients required mechanical support. TEER procedure was performed on the median 6 days after the index MI date IQR (3, 11). Procedural success was achieved in 87% of patients. The grade of MR was significantly decreased after the procedure. MR reduction to 0 or 1 + was achieved in 13 patients (57%), to 2 + in 7 patients (30%), P

Aims: Acute mitral regurgitation (MR) in the setting of myocardial infarction (MI) may be the result of papillary muscle rupture (PMR). This condition is associated with high morbidity and mortality. We aim to evaluate the feasibility of transcatheter edge‐to‐edge mitral valve repair (TEER) in this acute setting. Methods and results: We analysed data from the International Registry of MitraClip in Acute Mitral Regurgitation following acute Myocardial Infarction (IREMMI) of 30 centres in Europe, North America, and the middle east. We included patients with post‐MI PMR treated with TEER as a salvage procedure, and we evaluated immediate and 30‐day outcomes. Twenty‐three patients were included in this analysis (9 patients suffered complete papillary muscle rupture, 9 partial and 5 chordal rupture). The patients' mean age was 68 ± 14 years. Patients were at high surgical risk with median EuroSCORE II 27% (IQR 16, 28) and 20 out of 23 (87% were in cardiogenic shock). All patients were treated with vasopressors, and 17 out of 23 patients required mechanical support. TEER procedure was performed on the median 6 days after the index MI date IQR (3, 11). Procedural success was achieved in 87% of patients. The grade of MR was significantly decreased after the procedure. MR reduction to 0 or 1 + was achieved in 13 patients (57%), to 2 + in 7 patients (30%), P < 0.01. V‐Wave was reduced from 49 ± 8 mmHg to 26 ± 10 mmHg post‐procedure, P < 0.01. Sixteen out of 23 patients (70%) were discharged from hospital and 5 of them required reintervention with surgical mitral valve replacement. No additional death at 1 year was documented. Conclusions: TEER is a feasible therapy in critically ill patients with PMR due to a recent MI. TEER may have a role as salvage treatment or bridge to surgery in this population. [ABSTRACT FROM AUTHOR]

Background Percutaneous transvenous mitral commissurotomy (PTMC) is the first-line therapy of clinically significant rheumatic mitral stenosis. While the procedure is generally safe, new onset or aggravation of mitral regurgitation (MR) may occur, mainly due to commissural splitting and, less frequently, to leaflet tear and chordal rupture. Papillary muscle rupture (PMR) is exceedingly rare in this setting. Case summary A 74-year-old woman with a history of aortic valve replacement and prior rheumatic mitral commissurotomy presented for worsening exercise intolerance and exertional dyspnoea. Transthoracic echocardiography showed a mean pressure gradient of 10 mmHg and a mitral valve area of 1.0 cm², consistent with clinically significant mitral stenosis. Subsequent PTMC was complicated by anterolateral PMR. However, the resulting MR was unexpectedly only of mild-to-moderate severity. Because of residual mitral stenosis and persisting symptoms, surgical mechanical mitral valve replacement and tricuspid annuloplasty were performed 6 weeks after PTMC. Papillary muscle rupture was confirmed during surgery. Discussion We herein describe the occurrence of PMR induced by PTMC; the resulting MR was unexpectedly of mild-to-moderate severity, as a result of extensive rheumatic lesions limiting valve mobility. This case challenges the dogma according to which PMR invariably leads to severe MR. This might not be necessarily the case when it occurs following PTMC. [ABSTRACT FROM AUTHOR]

Hypervirulent Klebsiella pneumoniae (hvKP) causes multisite infections and abscesses. However, endocarditis is a rare presentation of hvKP infection. Herein, we report a case of K. pneumoniae native valve infective endocarditis secondary to community-acquired liver and prostate abscesses. The patient developed papillary muscle rupture, leading to mitral regurgitation, and underwent emergent mitral valve replacement. The diagnosis of endocarditis was confirmed microbiologically and histologically. The causative strain belonged to the hypermucoid K1 capsular genotype and possessed the rmpA gene. The genome sequence was deposited in GenBank under the accession number JAQZBZ000000000. [ABSTRACT FROM AUTHOR]

Acute mitral regurgitation (MR) secondary to papillary muscle rupture is a rare mechanical complication of acute myocardial infarction occurring in 0.05–0.26% of all cases of myocardial infarction. The only treatment is emergency mitral valve surgery with high operative mortality reaching up to 39%. The use of extracorporeal membrane oxygenator (ECMO) as a stabilization strategy and a bridge to recovery may potentially improve the outcome of such cases. Here, we report a case of acute MR presenting with cardiogenic shock and severe hypoxia that required insertion of veno-veno-arterial ECMO initially and followed by emergency mitral valve replacement. This strategy proved useful with full recovery of the patient. [ABSTRACT FROM AUTHOR]

Mechanical complications (MC) are rare but significant sequelae of acute myocardial infarction (AMI). Current data on sex differences in AMI with MC is limited. We queried the National Inpatient Sample database to identify adult patients with the primary diagnosis of AMI and MC. The main outcome of interest was sex difference in-hospital mortality. Secondary outcomes were sex differences in the incidence of acute kidney injury (AKI), major bleeding, use of inotropes, permanent pacemaker implantation (PPMI), performance of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), surgery (VSD repair and MV surgery), pericardiocentesis, use of mechanical circulatory support (MCS), ischemic stroke, and mechanical ventilation. Among AMI-MC cohort, in-hospital mortality was higher among females compared to males (41.24% vs 28.13%: aOR 1.39. 95% CI 1.079–1.798; p = 0.01). Among those who had VSD, females also had higher in-hospital mortality compared to males (56.7% vs 43.1%: aOR 1.74, 95% CI 1.12–2.69; p = 0.01). Females were less likely to receive CABG compared to males (12.03% vs 20%: aOR 0.49 95% CI 0.345–0.690; p < 0.001). Despite the decreasing trend in AMI admission, females had higher risk of MC and associated mortality. Significant sex disparities still exist in AMI treatment. [ABSTRACT FROM AUTHOR]

Papillary muscle rupture is usually caused by myocardial infarction although rare cases of non-ischemic etiology have also been described. Among these, infective endocarditis represents an important cause. Herein, we report a case due to Streptococcus agalactiae involving the posteromedial papillary muscle. Non-ischemic papillary muscle rupture should be suspected when there is no evidence of atherosclerotic coronary artery disease. In the febrile patient, infective endocarditis should be considered in the differential diagnosis. [ABSTRACT FROM AUTHOR]

Papillary muscle rupture is a fatal complication with a high operative mortality. Most patients experience cardiogenic shock and hypoxia due to pulmonary edema caused by severe mitral regurgitation. Although preoperative stabilization using a mechanical assist device potentially improves surgical outcomes, an appropriate strategy has not yet been established. ECPELLA, combining venoarterial extracorporeal membrane oxygenation and Impella, has the potential to stabilize preoperative status and improve outcome in patients with refractory cardiogenic shock due to papillary muscle rupture. Herein, we present 3 cases involving the efficacy of ECPELLA and our tips of surgical and ECPELLA management in patients with papillary muscle rupture. [ABSTRACT FROM AUTHOR]

Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized. [ABSTRACT FROM AUTHOR]

Background: Post‐acute myocardial infarction papillary muscle rupture (post‐AMI PMR) may present variable clinical scenarios and degree of emergency due to result of cardiogenic shock. Veno‐arterial extracorporeal life support (V‐A ECLS) has been proposed to improve extremely poor pre‐ or postoperative conditions. Information in this respect is scarce. Methods: From the CAUTION (meChanical complicAtion of acUte myocardial infarcTion: an InternatiOnal multiceNter cohort study) database (16 different Centers, data from 2001 to 2018), we extracted adult patients who were surgically treated for post‐AMI PMR and underwent pre‐ or/and postoperative V‐A ECLS support. The end‐points of this study were in‐hospital survival and ECLS complications. Results: From a total of 214 post‐AMI PMR patients submitted to surgery, V‐A ECLS was instituted in 23 (11%) patients. The median age was 61.7 years (range 46–81 years). Preoperatively, ECLS was commenced in 10 patients (43.5%), whereas intra/postoperative in the remaining 13. The most common V‐A ECLS indication was post‐cardiotomy shock, followed by preoperative cardiogenic shock and cardiac arrest. The median duration of V‐A ECLS was 4 days. V‐A ECLS complications occurred in more than half of the patients. Overall, in‐hospital mortality was 39.2% (9/23), compared to 22% (42/219) for the non‐ECLS group. Conclusions: In post‐AMI PMR patients, V‐A ECLS was used in almost 10% of the patients either to promote bridge to surgery or as postoperative support. Further investigations are required to better evaluate a potential for increased use and its effects of V‐A ECLS in such a context based on the still high perioperative mortality. [ABSTRACT FROM AUTHOR]

Background Papillary muscle rupture (PMR) is a catastrophic complication of acute myocardial infarction. However, the best timing and modality of circulatory support for surgery are unknown. Case Summary A 75-year-old man presented to the emergency room in our hospital for worsening shortness of breath accompanied by chest pain. Transthoracic echocardiograph showed severe mitral regurgitation (MR) with a flail posterior mitral valve leaflet, and coronary angiography demonstrated distal right coronary artery occlusion. We diagnosed as cardiogenic shock due to subacute myocardial infarction and ischaemic PMR. An Impella CP (Abiomed, Danvers, MA, USA) was introduced to improve haemodynamics. Despite the grade of MR was still severe, the mean blood pressure and pulmonary artery pressure improved 4 h after an Impella CP support. At day 8, the patient underwent elective mitral valve replacement with single coronary artery bypass grafting. Discussion PMR is a rare but lethal complication of acute myocardial infarction. Expeditious surgical treatment offers the optimal chance of survival, but the post-operative mortality or morbidity is very high. Therefore, preoperative stabilization can be closely correlated with outcomes in these patients. It was reported that directly unloading the left ventricle by an Impella decreased wall stress, external work, and myocardial oxygen consumption. Therefore, an Impella can be the most suitable mechanical circulatory support for PMR. In conclusion, Impella CP alone can become one of the suitable bridges to surgery in the patients with PMR. [ABSTRACT FROM AUTHOR]

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Acute mitral valve regurgitation (MR) is an emergency condition that requires an early diagnosis of the etiology and rapid management. Surgical intervention is the first-line treatment for acute severe MR. However, many patients are denied surgical intervention due to the acute risk of surgery. Transcatheter mitral valve repair (TMVr) is a less invasive technique and becoming a potential alternative to surgery in inoperable patients but is underrepresented in the literature. This review aims to discuss the published data on the use of TMVr in unstable MR patients presenting with acute or critical cardiac conditions.

Abstract Background Papillary muscle rupture due to infective endocarditis is a rare event and proper management of this condition has not been described in the literature. Our case aims to shed light on treatment strategies for these patients using the current guidelines. Case presentation This case presents a 58-year-old male with acute heart failure secondary to papillary muscle rupture. He underwent an en bloc resection of his mitral valve with a bioprosthetic valve replacement. Specimen pathology later showed necrotic papillary muscle due to infective endocarditis. The patient was further treated with antibiotic therapy. He recovered well post-operatively and continued to do well after discharge. Conclusion In patients who present with papillary muscle rupture secondary to infective endocarditis, clinical symptoms should drive the treatment strategy. Despite the etiology, early mitral valve surgery remains treatment of choice for patients who have papillary muscle rupture leading to acute heart failure. Culture-guided prolonged antibiotic treatment is vital in this category of patients, especially those who have a prosthetic valve implanted.

Papillary muscle rupture with severe acute mitral regurgitation is a rare complication of acute myocardial infarction (AMI) that causes pulmonary congestion and cardiogenic shock. Moreover, it has a poor prognosis. Surgical intervention, including revascularization, is indicated; however, surgical mortality remains high. We report the case of an 85-year-old woman with cardiogenic shock from severe acute mitral regurgitation, in whom a hybrid intervention, combining percutaneous coronary intervention with mitral valve replacement via minithoracotomy, was performed after post-infarction papillary muscle rupture. She was discharged in a favorable clinical condition. We describe a novel hybrid intervention for treating a rare complication of AMI, which could minimize surgical invasion in elderly patients, prevent disuse syndrome after the intervention, and improve prognosis. However, mitral valve surgery via minithoracotomy for emergency cases requires technical proficiency, as well as collaboration with other healthcare professionals, and the choice to perform this procedure requires careful consideration.

Acute mitral valve regurgitation (MR) is an emergency condition that requires an early diagnosis of the etiology and rapid management. Surgical intervention is the first‑line treatment for acute severe MR. However, many patients are denied surgical intervention due to the acute risk of surgery. Transcatheter mitral valve repair (TMVr) is a less invasive technique and becoming a potential alternative to surgery in inoperable patients but is underrepresented in the literature. This review aims to discuss the published data on the use of TMVr in unstable MR patients presenting with acute or critical cardiac conditions. [ABSTRACT FROM AUTHOR]

Mechanical complications of myocardial infarction include rupture of a papillary muscle, ventricular septum, and free wall. Since the advent of acute coronary reperfusion, there has been a significant reduction in the incidence of these complications. One must have a high index of suspicion for a mechanical complication in any patient who develops cardiogenic shock in the days following a myocardial infarction. The most important diagnostic investigation in evaluation of these complications is echocardiography. Although there is a role for mechanical circulatory support, urgent surgical repair is required in most cases. We will review the predictors, clinical features, diagnostic, and management strategies in patients with these complications. [ABSTRACT FROM AUTHOR]

Cardiac injury is a common unexpected injury with high rate of mortality in multi-trauma patients. Blunt thoracic trauma leading to heart injury presented with variable presentations from myocardial contusion to rupture. Cardiac injury is about 15% - 25% of blunt chest trauma. Cardiac contusion is the most common type of injury with variable manifestations associated with electrocardiogram (ECG) changes or cardiac enzyme abnormality. Traumatic rupture of intra-cardiac structures after blunt Thoracic trauma is an uncommon. Cardiac valves rupture is uncommon, and the most frequent being aortic valve, and then followed by mitral and tricuspid. Nowadays, the incidence of these types of injury is increasing due to high increase of road traffic accidents (RTA). Following blunt thoracic trauma, rupture of papillary muscle or its chordae tendineae is a very rare causing acute mitral regurgitation (MR) with sequence of congestive heart failure (HF) and pulmonary edema.

Background: Papillary muscle rupture due to infective endocarditis is a rare event and proper management of this condition has not been described in the literature. Our case aims to shed light on treatment strategies for these patients using the current guidelines.Case Presentation: This case presents a 58-year-old male with acute heart failure secondary to papillary muscle rupture. He underwent an en bloc resection of his mitral valve with a bioprosthetic valve replacement. Specimen pathology later showed necrotic papillary muscle due to infective endocarditis. The patient was further treated with antibiotic therapy. He recovered well post-operatively and continued to do well after discharge.Conclusion: In patients who present with papillary muscle rupture secondary to infective endocarditis, clinical symptoms should drive the treatment strategy. Despite the etiology, early mitral valve surgery remains treatment of choice for patients who have papillary muscle rupture leading to acute heart failure. Culture-guided prolonged antibiotic treatment is vital in this category of patients, especially those who have a prosthetic valve implanted. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. METHODS Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. RESULTS A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07–6.45, P  =   0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02–15.61, P  =   0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00–1.02, P  =   0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16–0.92, P  =   0.031). CONCLUSIONS Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. Clinical trial registration clinicaltrials.gov: NCT03848429. [ABSTRACT FROM AUTHOR]

Background Acute papillary muscle (PM) rupture due to infective involvement has been recognized as a complication of infective endocarditis. However, there is very limited literature describing the rupture of the posteromedial PM in primary aortic valve endocarditis without aortic root abscess. This report highlights the aetiology of the PM rupture in the setting of primary aortic valve endocarditis and the importance of a multidisciplinary approach. Case summary An 81-year-old man without any heart failure symptoms presented with fever and loss of vision in his left eye. Initial echocardiography revealed moderate aortic valve regurgitation due to a perforated right coronary cusp without aortic root abscess, and his blood cultures were positive for Group G Streptococci. During adequate antibiotic therapy, he developed acute severe mitral regurgitation secondary to posteromedial PM rupture. Following emergent aortic and mitral valve replacement using bioprosthetic valves, he made excellent progress on a 6-week course of intravenous antibiotics. Discussion The echocardiography and the histological findings suggested that the main cause of PM rupture was most likely a metastatic focus of infection from the aortic valve via a regurgitant jet. Successful treatment of this fatal complication includes early diagnosis and prompt surgical intervention by a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Papillary muscle rupture (PMR) is a catastrophic complication of acute myocardial infarction (AMI). We report on 3 consecutive patients with AMI cardiogenic shock due to PMR, treated with combined venoarterial extracorporeal membrane oxygenation and Impella-CP axial flow circulatory support as a bridge to definitive surgery. (Level of Difficulty: Intermediate.)

Mechanical complications (MC) (i.e., free wall rupture (FWR), papillary muscle rupture (PMR) and ventricular septal rupture (VSR)) are rare complications of ST- elevation acute myocardial infarction (STEMI). Incidence of MC according to pre-hospital delay remains unknown. We aimed to determine the rates of MC according to pre-hospital delay. Analysis was conducted on the MODIF registry data. Patients were allocated to four groups according to pre-hospital delay: 0 to 12 h, 12 to 24 h, 24 to 36 h and 36 to 48 h. 6185 patients with complete data were analyzed. Mean age was 64.1 years old and 75.7% of patients were males. Eighty-three patients (1.34%) presented with MC: 44 (0.71%) experienced a FWR, 17 (0.27%) a PMR, and 22 (0.36%) a VSR. Global rates of MC were 0.82%, 1.43%, 1.24% and 5.07% in the four groups of pre-hospital delays - 0 to 12 h, 12 to 24 h, 24 to 36 h and 36 to 48 h - respectively (p < 0.001). In-hospital mortality rates were high: 44.2%, 47.1% and 54.6% for FWR, PMR and VSR, respectively. In multivariate analysis, factors independently related to the occurrence of MC were older age, female sex, simultaneous COVID-19 infection, absence of dyslipidemia, initial TIMI flow 0 or 1 in the culprit artery, 36 to 48 h-pre-hospital delay and absence of revascularization by percutaneous coronary intervention (PCI) with stent implantation. The probability of MC in STEMI increases with pre-hospital delay. Mechanical complications of STEMI remain associated with a very poor prognosis. [Display omitted] • Data on mechanical complications in STEMI are scarce and outdated. • The present study describes, from a large contemporary nationwide database, the correlation between pre-hospital delay and mechanical complication occurrence. • Probability of Mechanical Complication in STEMI increases with pre-hospital delay, in particular over 36 h. [ABSTRACT FROM AUTHOR]

A 57-year-old man acutely developed chest tightness and dyspnea. Given concern that his symptoms were consistent with COVID-19, the patient self-isolated. After 1 week of worsening symptoms, the patient presented with hypoxia and hypotension. He was found to have an occluded right coronary artery and ruptured posteromedial papillary muscle. (Level of Difficulty: Beginner.)

Mechanical complications of acute myocardial infarction are infrequent in the modern era of primary percutaneous coronary intervention, but they are associated with high mortality rates. Papillary muscle rupture with acute severe mitral regurgitation is one such life-threatening complication that requires early detection and urgent surgical intervention. (Level of Difficulty: Beginner.)

Rupture of a papillary muscle after acute myocardial infarction is a rare but potentially fatal complication. It can lead to acute, severe mitral regurgitation, pulmonary edema, cardiogenic shock, and death. Immediate surgical intervention in the form of mitral valve repair/replacement with concomitant coronary revascularization can reduce mortality. We herein report such a case who presented with cardiogenic shock and made a successful outcome after emergent surgery. [ABSTRACT FROM AUTHOR]

Cardiac injury is a common unexpected injury with high rate of mortality in multitrauma patients. Blunt thoracic trauma leading to heart injury presented with variable presentations from myocardial contusion to rupture. Cardiac injury is about 15% - 25% of blunt chest trauma. Cardiac contusion is the most common type of injury with variable manifestations associated with electrocardiogram (ECG) changes or cardiac enzyme abnormality. Traumatic rupture of intra-cardiac structures after blunt Thoracic trauma is an uncommon. Cardiac valves rupture is uncommon, and the most frequent being aortic valve, and then followed by mitral and tricuspid. Nowadays, the incidence of these types of injury is increasing due to high increase of road traffic accidents (RTA). Following blunt thoracic trauma, rupture of papillary muscle or its chordae tendineae is a very rare causing acute mitral regurgitation (MR) with sequence of congestive heart failure (HF) and pulmonary edema. [ABSTRACT FROM AUTHOR]

Papillary muscle rupture (PMR) is an uncommon mechanical complication of myocardial infarction which warrants timely diagnosis and urgent surgical intervention to maximize survival chances. Echocardiography is an essential diagnostic tool, whereas transesophageal echocardiography can provide accurate diagnosis and guide decision-making. We hereby present the case of a patient with partial PMR that presented for cardiac surgery in our institution, with the respective intraoperative echocardiographic findings. [ABSTRACT FROM AUTHOR]

Papillary muscle rupture is one of the rarest complications, with incidence of 1-5% 1 in patients with acute myocardial infarction (AMI), and usually happens 5-7 days after the initial event. This complication has a high mortality of 50% in the first 24hours, often leading to decompensation and pulmonary edema. The acute rupture and the severe dysfunction of the mitral leaflet finally result in a severe mitral regurgitation and in most of the cases leads to cardiogenic shock and death. The competence of the mitral valve is maintained by the actions of the anterolateral and posteromedial papillary muscles, but this mechanical complication occurs dominantly on the posteromedial muscle, with greater incidence of more than ten times compared to the anterolateral one. Transthoracic echocardiography (TTE) is a diagnostic tool with 65-85% sensitivity in visualizing structural abnormalities of the heart and is the most available and fast method in diagnostic this mechanical complication. Beside the structural abnormalities that can be detected, echocardiography can provide precise assessment of the regurgitant jet through the color doppler and continuous doppler ultrasound. It is very important to follow the guidelines from both the European and the American heart associations that recommend urgent echocardiography in patients that become hemodynamically unstable during or after acute myocardial infarction. However, the diagnosis of papillary muscle rupture is not always easy because patients are often elderly and frequently diagnosed with a particularly severe clinical presentation, or hemodynamic instability, which are all factors associated with high operative mortality. The only definite treatment for this condition is the cardiosurgical treatment, which in the last 10 years has an improved success and reduced mortality2 . Intra-aortic balloon counter-pulsation may be necessary for severely unstable patients, or other mechanical circulatory support devices. Mitral valve repair can be done in patients who have a partial papillary muscle rupture, in case of detachment of the main insertion of a head which still remains fixed to the remnant papillary muscle via muscular bridges, unlike the complete rupture (or rupture of the main head) where mitral valve replacement is the main surgical therapy because complete post-MI papillary muscle rupture generally requires MVR due to the friable infarcted tissue. We describe a clinical case of a patient with severe mitral regurgitation after acute myocardial infarction and discuss the management for such patients in the current era. [ABSTRACT FROM AUTHOR]

The prognosis of papillary muscle rupture (PMR) leading to acute mitral regurgitation, pulmonary oedema, and cardiogenic shock remains dismal, with survival dependent on prompt recognition and surgical intervention. The use of extracorporeal membrane oxygenation (ECMO) for circulatory and/or respiratory support in critically ill patients failing conventional treatment has significantly increased in the past few years, mainly owing to technology improvements that have rendered the provision of this technique simpler and safer. In this report, four cases of refractory cardiopulmonary collapse complicating ischaemic and traumatic PMR successfully managed perioperatively with ECMO are presented. In this context, a review of the potential role of perioperative ECMO support for cardiogenic shock secondary to cardiac mechanical complications is also provided. [ABSTRACT FROM AUTHOR]

Competing Interests: Declaration of Competing Interest Dr. Smith receives consulting fees from Abbott Laboratories, GE Healthcare, and Edwards Lifesciences. The remaining authors have no competing interests to declare.

Background and Aims: Mechanical complications (MCs) are rare but potentially fatal sequelae of acute myocardial infarction (AMI). Surgery, though challenging, is considered the treatment of choice. The authors sought to study early and long-term results of patients undergoing surgical treatment for post-AMI MCs., Methods: Patients undergone surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centers worldwide were retrieved from the database of CAUTION study. In-hospital and long-term mortality were the primary outcomes. Cox proportional hazards regression models were used to determine independent factors associated with overall mortality., Results: The study included 720 patients. The median age was 70.0 [62.0-77.0] years, with a male predominance (64.6%). The most common MC encountered was ventricular septal rupture (VSR) (59.4%). Cardiogenic shock was seen on presentation in 56.1% of patients. In-hospital mortality rate was 37.4%; in more than 50% of cases, the cause of death was low cardiac output syndrome (LCOS). Late mortality occurred in 133 patients, with a median follow-up of 4.4 [1.0-8.6] years. Overall survival at 1, 5 and 10 years was 54.0%, 48.1% and 41.0%, respectively. Older age (p < 0.001) and postoperative LCOS (p < 0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significant higher for patients with VSR than those with papillary muscle rupture (long-rank P = 0.022)., Conclusions: Contemporary data from a multicenter cohort study show that surgical treatment for post-AMI MCs continues to be associated with high in-hospital mortality rates. However, long-term survival in patients surviving the immediate postoperative period is encouraging.Trial registration number: NCT03848429., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

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. [ABSTRACT FROM AUTHOR]

The rupture of mitral papillary muscles is a very rare complication of infective endocarditis (IE). We report a case of anterolateral papillary muscle rupture resulting in severe mitral regurgitation due to IE in a young man without previous heart disease. The patient underwent urgent mitral valve replacement. The isolated rupture of the mitral papillary muscle complicating IE is rare. Urgent surgery should be performed is such cases. [ABSTRACT FROM AUTHOR]

Background Acute heart failure caused by severe mitral regurgitation (MR) due to papillary muscle rupture has been described in the puerperium by case reports; however, the majority of cases of papillary muscle rupture are caused by myocardial infarction. We describe papillary muscle rupture occurring in the postpartum period in a patient with systemic lupus erythematosus (SLE), antiphospholipid syndrome (APLS), and chronic Libman–Sacks endocarditis and explore the multifactorial nature of the papillary muscle infarction and rupture in the setting of postpartum fluid shifts, chronic myocardial injury from Libman–Sacks, and high thrombotic risk. Case summary A 29-year-old woman presented with acute heart failure 2 weeks' postpartum and was found to have acute MR due to a flail leaflet caused by papillary muscle rupture. She proceeded to emergency surgery with mitral valve (MV) replacement and the histology revealed evidence of chronic Libman–Sacks endocarditis and papillary muscle infarction with thrombi in the intramyocardial arteries. Discussion This is the second case report of papillary muscle rupture in the puerperium in a patient with SLE in the literature, the other case was caused by catastrophic APLS. However, in this case, the cause of the rupture is likely to be multifactorial; as a consequence of thrombosis in the microvasculature causing isolated papillary muscle ischaemia, and fibrosis of the muscle due to chronic Libman–Sacks endocarditis resulting in limited pliability which caused rupture of the papillary muscle when faced with the added stress of increased volume that occurs in the puerperium. [ABSTRACT FROM AUTHOR]

To explore the value of echocardiography in diagnosing papillary muscle rupture (PMR) of the mitral valve, and summarize the characteristic echocardiographic features of different types. Echocardiograms of 13 PMR patients confirmed by surgery in Wuhan Union Hospital between January 2009 and December 2022 were retrospectively analyzed and their preoperative transthoracic echocardiography (TTE) was compared with surgical findings. A total of 9020 patients underwent mitral valve repair or replacement surgery during the study period including 13 (0.14%) for PMR. Of the 13 PMRs, 8 cases were partial PMR(P-PMR), 5 cases were complete PMR(C-PMR); 3 cases were anterolateral PMR, and 10 were posteromedial PMR. The diagnostic accuracy, sensitivity, and specificity of the preoperative TTE were 99.9%, 53.8% and 99.9% respectively. Echocardiographic features of 10 patients (5-C-PMR and 5 P-PMR) with detailed TTE and intraoperative transesophageal echocardiography (TEE) data included: both anterior and posterior leaflets prolapse (C-PMR 60% vs P-PMR 60%); flail leaflet (C-PMR100% vs P-PMR 40%); All C-PMRs and P-PMRs have severe, eccentric and lateral regurgitation; flail attachment (chordae tendinae and ruptured PM) at the tip of prolapsed leaflet (C-PMR100% vs P-PMR 60%); high-echo masses resembled "champagne glasses" in 100% of the C-PMR; high-echo masses resembled "lotus-seedpod" in 60% and "dumbbell-shaped" torn PM in remaining 40% of the P-PMR. Different PMR subtypes have different echocardiographic characteristics. Combining TTE and TEE can accurately identify the typical features of PMR such as ipsilateral hemipetal leaflet prolapse, high-echoic mass at the tip of the leaflet, massive eccentricity and lateral regurgitation. • Accurate diagnosis of mitral papillary muscle rupture (PMR) by sonographers is challenging due to its rarity. • Ipsilateral hemipetal leaflet prolapse, high-echoic mass at the tip of the leaflet, massive eccentricity and lateral regurgitation are typical features of PMR. • From an ultrasound perspective, a detailed typing of PMR for all types of anatomical variants of the papillary muscle was performed. [ABSTRACT FROM AUTHOR]

Blunt cardiac injury is caused by large deceleration forces seen in motor vehicle accidents and can range from non–life-threatening arrhythmias to potentially fatal cardiac conditions such as valve disruption. A 28-year-old man presented following a motor vehicle accident involving direct blunt-force chest trauma. He developed papillary muscle rupture resulting in mitral valve dysfunction. Diagnosis was delayed due to concomitant chest pathology. Diagnosis of cardiac valvular injuries may be difficult due to concomitant injuries in a trauma patient. Though rare, papillary muscle rupture should be included in the differential diagnosis following blunt thoracic trauma, particularly involving persistent hypoxemia. [ABSTRACT FROM AUTHOR]

A previously healthy 61-year-old man presented to the emergency department with chest pain and dyspnoea for 6 hours. Examination revealed distress with an apical pansystolic murmur. Initial electrocardiogram showed sinus tachycardia and ST elevation in leads II, III, and aVF compatible with an inferior ST-elevation myocardial infarction. Point-of-care echocardiography in the emergency department showed a flail anterior mitral leaflet and severe mitral regurgitation, leading to a provisional diagnosis of papillary muscle rupture. Emergency cardiac catheterization showed 100%, 80%, and 70% occlusion of the middle right coronary, left anterior descending, and left circumflex arteries, respectively. An emergency triple vessel coronary artery bypass grafting and mitral valve replacement was performed. Posteromedial papillary muscle rupture resulting in mitral regurgitation was confirmed intraoperatively. The patient recovered uneventfully. In the absence of primary percutaneous coronary intervention, thrombolysis decisions should be made with extreme caution if mechanical complications of ST-elevation myocardial infarction are suspected.