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Echocardiographic Recognition of Partial Papillary Muscle Rupture
Echocardiographic Recognition of Partial Papillary Muscle Rupture J. Timothy Hanlon, MD, A. Kelly Conrad, MD, D. Thomas Combs, MD, Bruce A. McLellan, MD, and Karen Doolan, RDMS, Bend, Oregon
Acute papillary muscle rupture complicating acute myocardial infarction represents a potentially lethal complication of acute myocardial infarction. Survival depends on prompt recognition and institution of immediate medical and surgical therapy. We present two cases of partial papillary muscle rupture in the setting of acute myocardial infarction and describe the echocardiographic features that may allow early recognition of this condition before complete rupture. (JAM Soc EcHOCARDIOGR 1993;6:101-3.) From the Bend Memorial Clinic and St. Charles Medical Center. Reprint requests: J. Timothy Hanlon, MD, 1501 N.E. Medical Center Dr., Bend, OR 97701. Copyright© 1993 by the American Society ofEchocardiography. 0894-7317/93 $1.00 + .10 27/1141939
Acute papillary muscle rupture complicating myocardial infarction is generally rapidly fatal. 1 Recognition of partial rupture of the head of a papillary muscle could be life-saving by allowing medical-surgical intervention before catastrophic complete rupture. We describe two patients with acute partial papillary muscle rupture complicating acute myocardial infarction diagnosed by transthoracic and transesophageal echocardiography.
Site of rupture with ~f'!'lafl strand of rema1mng muscle
B Figure 1 Transesophageal echocardiogram (A) and corresponding diagram (B) in horizontal plane showing area of partial papillary muscle rupture (arrows). In real time, marked mobility of the proximal portion of the papillary muscle could be appreciated. 101
Journal of the American Society of Echocardiography January· February 1993
102 Hanlon et a!.
fused surgical intervention and died approximately 30 minutes later of acute pulmonary edema.
Case2
Figure 2 Precordial apical long-axis plane showing area of partial papillary muscle rupture (arrow).
A 55-year-old man came to the emergency department with complaints of chest pain through the night and a lower than normal blood pressure (taken by his wife). Physical examination showed a slightly tachypneic man with sinus tachycardia at a rate of ll5 I minute, bibasilar rales, and a soft apical systolic murmur. Electrocardiogram showed recent transmural inferior myocardial infarction. Transthoracic echocardiography was performed demonstrating a mobile mass partially attached to the inferior-posterior wall of the left ventricle (Figure 2) consistent with partial papillary muscle rupture. While moving the patient onto the catheterization table, sudden hemodynamic deterioration occurred with cardiagenic shock and severe pulmonary edema. Intubation and mechanical ventilation were instituted, an intraaortic balloon was placed, and left ventricular angiography demonstrated severe mitral regurgitation. The patient was transferred to the operating room where complete cardiac arrest with ventricular fibrillation occurred before he was prepped and draped. Emergent mitral valve replacement was performed for complete papillary muscle rupture. The patient subsequently recovered and was discharged after a prolonged hospitalization. DISCUSSION
CASE REPORTS
easel A 73-year-old man was transferred from a community hospital with chest pain that had been present for approximately 10 hours. Physical examination showed an ill-appearing patient with a blood pressure of 100 I 60 mm Hg, audible pulmonary rales, and a soft apical systolic murmur. Transthoracic echocardiography was suggestive of partial papillary muscle rupture and transesophageal echocardiography was urgently performed in the emergency department, demonstrating definite incomplete papillary muscle rupture with a mobile, partially attached portion of the papillary muscle (Figure 1, A and B). While the patient was being transported to the catheterization laboratory his condition suddenly deteriorated and left ventricular angiography demonstrated severe mitral regurgitation. The patient re-
Rupture of a papillary muscle occurs rarely as a complication of acute myocardial infarction, but without surgical therapy massive pulmonary edema results in death in 50% of patients within 24 hours and 90% within 1 week. In 1978, Ahmad et al. 2 described preliminary echocardiographic observations suggesting papillary muscle rupture, and subsequently numerous reports 3· 5 have described transthoracic and transesophageal features of acute complete papillary muscle rupture. To date, however, only three cases of echocardiographically recognized partial papillary muscle rupture have been reported. 6•7 Each of our two patients had recent inferior myocardial infarction, soft apical murmurs, and mild pulmonary vascular congestion but were otherwise hemodynamically stable. Echocardiography in each patient, however, revealed evidence of partial dis-
Journal of the American Society of Echocardiography Volume 6, Number l
ruption of the posteromedial papillary muscle exactly as described previously. 6 •7 The condition of both patients suddenly and dramatically deteriorated, resulting in death in one and acute medical and surgical intervention in the other with resultant survival. In each of these two patients, echocardiography showed a disruption in the continuity of the papillary muscle with an obvious mobile mass still attached by a small strand to the remainder of the papillary muscle left ventricular wall. These two cases conform so closely with the other three reported cases that we believe it is possible to make a definitive diagnosis of partial papillary muscle rupture by the combined use of transthoracic and, when necessary, transesophageal echocardiography. The acute decompensation witnessed with these two patients and the surgical findings of complete papillary muscle rupture confirm the gravity of the lesion (and its propensity to progress to complete rupture) and argue for emergent catheterization and surgery to avoid acute hemodynamic collapse. By virtue of its portability, ready availability, and potential to limit contrast load, echocardiography may allow prompt recognition of partial papillary muscle rupture early enough in its course to allow a window of opportunity to institute appropriate aggressive medical and surgical therapy before complete mitral rupture.
Hanlon eta!.
103
REFERENCES L Nishimura RA, SchaffHV, Suub C, Gersch BJ, Edwards WD, Tajik AJ. Papillary muscle rupture complicating acute myocardial infarction: analysis of 17 patients. Am J Cardiol 1983;51:373-7. 2. Ahmad S, Kleiger RE, Connors J, Krone R. The echocardiographic diagnosis of rupture of a papillary muscle. Chest 1978;73:232-4. 3. Buda AJ. The role of echocardiography in the evaluation of mechanical complications of acute myocardial infarction. Circulation 1991;84:1-109-21. 4. Stoddard MF, Keedy DL, Kupersmith J. Transesophageal echocardiographic diagnosis of papillary muscle rupture complicating acute myocardial infarction. Am Heart J 1990;120:690-2. 5. Patel A, Miller F, Khandheria B, Mullany C, Seward J, Oh J. Role of transesophageal echocardiography in the diagnosis of papillary muscle rupture secondary to myocardial infarction. Am Heart J 1989;118:1330-3. 6. Nishimura RA, Shub C, Tajik AJ. Two-dimensional echocardiographic diagnosis of partial papillary muscle rupture. Br Heart J 1982;48:598-600. 7. Come PC, Riley MF, Weintraub R, Morgan JP, Nakao S. Echocardiographic detection of complete and partial papillary muscle rupture during acute myocardial infarction. Am J Cardiol1985;56:787-9.
Acute papillary muscle rupture complicating acute myocardial infarction represents a potentially lethal complication of acute myocardial infarction. Survival depends on prompt recognition and institution of immediate medical and surgical therapy. We present two cases of partial papillary muscle rupture in the setting of acute myocardial infarction and describe the echocardiographic features that may allow early recognition of this condition before complete rupture. (JAM Soc EcHOCARDIOGR 1993;6:101-3.) From the Bend Memorial Clinic and St. Charles Medical Center. Reprint requests: J. Timothy Hanlon, MD, 1501 N.E. Medical Center Dr., Bend, OR 97701. Copyright© 1993 by the American Society ofEchocardiography. 0894-7317/93 $1.00 + .10 27/1141939
Acute papillary muscle rupture complicating myocardial infarction is generally rapidly fatal. 1 Recognition of partial rupture of the head of a papillary muscle could be life-saving by allowing medical-surgical intervention before catastrophic complete rupture. We describe two patients with acute partial papillary muscle rupture complicating acute myocardial infarction diagnosed by transthoracic and transesophageal echocardiography.
Site of rupture with ~f'!'lafl strand of rema1mng muscle
B Figure 1 Transesophageal echocardiogram (A) and corresponding diagram (B) in horizontal plane showing area of partial papillary muscle rupture (arrows). In real time, marked mobility of the proximal portion of the papillary muscle could be appreciated. 101
Journal of the American Society of Echocardiography January· February 1993
102 Hanlon et a!.
fused surgical intervention and died approximately 30 minutes later of acute pulmonary edema.
Case2
Figure 2 Precordial apical long-axis plane showing area of partial papillary muscle rupture (arrow).
A 55-year-old man came to the emergency department with complaints of chest pain through the night and a lower than normal blood pressure (taken by his wife). Physical examination showed a slightly tachypneic man with sinus tachycardia at a rate of ll5 I minute, bibasilar rales, and a soft apical systolic murmur. Electrocardiogram showed recent transmural inferior myocardial infarction. Transthoracic echocardiography was performed demonstrating a mobile mass partially attached to the inferior-posterior wall of the left ventricle (Figure 2) consistent with partial papillary muscle rupture. While moving the patient onto the catheterization table, sudden hemodynamic deterioration occurred with cardiagenic shock and severe pulmonary edema. Intubation and mechanical ventilation were instituted, an intraaortic balloon was placed, and left ventricular angiography demonstrated severe mitral regurgitation. The patient was transferred to the operating room where complete cardiac arrest with ventricular fibrillation occurred before he was prepped and draped. Emergent mitral valve replacement was performed for complete papillary muscle rupture. The patient subsequently recovered and was discharged after a prolonged hospitalization. DISCUSSION
CASE REPORTS
easel A 73-year-old man was transferred from a community hospital with chest pain that had been present for approximately 10 hours. Physical examination showed an ill-appearing patient with a blood pressure of 100 I 60 mm Hg, audible pulmonary rales, and a soft apical systolic murmur. Transthoracic echocardiography was suggestive of partial papillary muscle rupture and transesophageal echocardiography was urgently performed in the emergency department, demonstrating definite incomplete papillary muscle rupture with a mobile, partially attached portion of the papillary muscle (Figure 1, A and B). While the patient was being transported to the catheterization laboratory his condition suddenly deteriorated and left ventricular angiography demonstrated severe mitral regurgitation. The patient re-
Rupture of a papillary muscle occurs rarely as a complication of acute myocardial infarction, but without surgical therapy massive pulmonary edema results in death in 50% of patients within 24 hours and 90% within 1 week. In 1978, Ahmad et al. 2 described preliminary echocardiographic observations suggesting papillary muscle rupture, and subsequently numerous reports 3· 5 have described transthoracic and transesophageal features of acute complete papillary muscle rupture. To date, however, only three cases of echocardiographically recognized partial papillary muscle rupture have been reported. 6•7 Each of our two patients had recent inferior myocardial infarction, soft apical murmurs, and mild pulmonary vascular congestion but were otherwise hemodynamically stable. Echocardiography in each patient, however, revealed evidence of partial dis-
Journal of the American Society of Echocardiography Volume 6, Number l
ruption of the posteromedial papillary muscle exactly as described previously. 6 •7 The condition of both patients suddenly and dramatically deteriorated, resulting in death in one and acute medical and surgical intervention in the other with resultant survival. In each of these two patients, echocardiography showed a disruption in the continuity of the papillary muscle with an obvious mobile mass still attached by a small strand to the remainder of the papillary muscle left ventricular wall. These two cases conform so closely with the other three reported cases that we believe it is possible to make a definitive diagnosis of partial papillary muscle rupture by the combined use of transthoracic and, when necessary, transesophageal echocardiography. The acute decompensation witnessed with these two patients and the surgical findings of complete papillary muscle rupture confirm the gravity of the lesion (and its propensity to progress to complete rupture) and argue for emergent catheterization and surgery to avoid acute hemodynamic collapse. By virtue of its portability, ready availability, and potential to limit contrast load, echocardiography may allow prompt recognition of partial papillary muscle rupture early enough in its course to allow a window of opportunity to institute appropriate aggressive medical and surgical therapy before complete mitral rupture.
Hanlon eta!.
103
REFERENCES L Nishimura RA, SchaffHV, Suub C, Gersch BJ, Edwards WD, Tajik AJ. Papillary muscle rupture complicating acute myocardial infarction: analysis of 17 patients. Am J Cardiol 1983;51:373-7. 2. Ahmad S, Kleiger RE, Connors J, Krone R. The echocardiographic diagnosis of rupture of a papillary muscle. Chest 1978;73:232-4. 3. Buda AJ. The role of echocardiography in the evaluation of mechanical complications of acute myocardial infarction. Circulation 1991;84:1-109-21. 4. Stoddard MF, Keedy DL, Kupersmith J. Transesophageal echocardiographic diagnosis of papillary muscle rupture complicating acute myocardial infarction. Am Heart J 1990;120:690-2. 5. Patel A, Miller F, Khandheria B, Mullany C, Seward J, Oh J. Role of transesophageal echocardiography in the diagnosis of papillary muscle rupture secondary to myocardial infarction. Am Heart J 1989;118:1330-3. 6. Nishimura RA, Shub C, Tajik AJ. Two-dimensional echocardiographic diagnosis of partial papillary muscle rupture. Br Heart J 1982;48:598-600. 7. Come PC, Riley MF, Weintraub R, Morgan JP, Nakao S. Echocardiographic detection of complete and partial papillary muscle rupture during acute myocardial infarction. Am J Cardiol1985;56:787-9.