- Email: [email protected]
Echocardiographic detection of complete and partial papillary muscle rupture during acute myocardial infarction
RIEF REPORTS
because of the echocardiographic diagnosis of partial papillary muscle rupture. Severe mitral regurgitation had not been suspected before echocardiography in the third patient with partial rupture. In the fourth patient, the presence of a mechanical defect in the setting of preserved septal and anterior wall motion prompted surgery. Our 4 patients illustrate the spectrum of echocardiographic abnormalities that may be found in patients with complete or partial papillary muscle ‘rupture. Complete papillary muscle rupture may be characterized by 1 or more 2-dimensional findings: abnormal cut-off of 1 papillary muscle; a mobile mass attached to chordae and to the mitral valve, which could simulate a valvular tumor, thrombus or vegetation; and a pattern of mitral prolapse or of a flail mitral leaflet.1-4 Partial papillary muscle rupture has been reported only once previously. Nishimura et al5 described an echocardio-
of Complete and Partial Papillary Muscle Rupture During Acute Myocardial Infarction PATRICIA C. COME, MD MARILYN F. RILEY, BS RONALD WEINTRAUB, MD JAMES P. MORGAN, MD, PhD SHOICHIRO NAKAO, MD
Papillary muscle rupture produces severe mitral regurgitation, which is generally rapidly fatal. Because echocardiography can visualize the papillary muscles and mitral leaflets, it may detect papillary muscle rupture, prompting aggressive medical and surgical therapy. In 4 patients presenting to our hospital in 1983 and 1984, emergency echocardiography was instrumental in diagnosing either complete or partial papillary muscle rupture. Characteristics of the patient population are listed in Table I and pertinent echocardiographic features are illustrated in Figures 1 to 6. In our 4 patients, echocardiography played a pivotal role in diagnosis and therapy. In the first patient, with complete papillary muscle rupture, there was no audible precordial murmur, and the initial pulmonary artery wedge pressure tracing inexplicably failed to reveal large “v” waves. In the second patient, mitral regurgitation was audible, but the patient improved markedly with vasodilator therapy. Emergency surgery was performed From the Charles A. Dana Research Institute and the Harvard-Thorndike Laboratory of the Beth Israel Hospital, Departments of Medicine and Surgery, Beth Israel Hospital and Harvard Medical School, Boston, Massachusetts. Manuscript received December 13, 1984; revised manuscript received May IO, 1985, accepted May 13, 1985.
Apical views of the left ventricle (LV) obtained with slight transducer angulation, from the second patient, in whom partial rupture of the posterior papillary muscle (PM) was confirmed at surgery. There is marked thinning of a localized portion of the inferoposterior wall (area between the 2 unlabeled black arrows). This region of myocardium was akinetic on the 2-dimensional scan. To no definite connection can be seen between the inferoposterior wal; and the papillary muscle. With a slight change in transducer angulation, (bottom), however, a thread-like connection (white arrow) is evident, attaching the papillary muscle to the distal portion of the thinned myocardial region. There was increased echo-reflectivity from the papillary muscles, suggesting fibrosis.
FKXJRE 1. Long-axis diastolic (left) and apical systolic (right) images in the first patient, who had rupture of the posterior papillary muscle confirmed at surgery. In diastole, transection of 1 of the papillary muscles (PM) is seen. During systole, the PM is seen to flail into the left atrium (LA) (right). ANT MV = anterior mitral valve leaflet; AoV = aortic valve; LV = left ventricle; SG = Swan Ganz catheter in the right side of the heart. 787
78%
BRIEF
REPORTS
Fl&JRE 3. Apical 2-dimensional echocardiogram (left) and Doppler echocardiqraphic recording (right) from the second patient reveals holosystolic turbulence (between 2 black arrows) with sample volume placement (unlabeled white arrow) at the back wall of the left atrium (LA). EKG = electrocardiogram; LV = left ventricle; MV = mitral valve.
FIGURE 4. Apical views of the left ventricle (LV) in the third patient, with partial rupture of the posteromedial papillary muscle. Left, a tenuous attachment of the papillary muscle (PM) to the posterior wall is evident (arrowhead). Mlddle and right, dropout of myocardial echoes in the regions where PM attachment would be expected (longer arrows) and eliminate systolic protrusion of part of the PM into and through (short arrow) the mitral valve. LA = left artium.
FIGURE 5. Apical views of the left ventricle (LV) in the fourth patient, with complete papillary muscle (PM) rupture. In diastole (left), the PM was seen to fling freely within the LV. In systole (right), the PM was thrust into the left atrium (LA). The flail motion of the anterior mitral valve (MV) leaflet is not evident in this view. RA = right atrium.
T
TABLE I Age WI &Sex
Pt 1
45F
3” 4
82F 67F 84M
Characteristics
Location AMI Inferior Inferior Inferior
of the Patients Interval (days) from Onset of AMI to G!inical Deterioration
APE
+
21 5 7
0 T
SAP (s/d) (mm Hg) 50/120/80 601” 40/-
Mean PAWP (mm Hg)
Precordial Murmur
30 26 +(2/6) +(3/6)
“28
PM Rupture (l/zn)
MVR
Died
Partial
2 2.9 “T2
Measurements performed after institution of intraaortic balloon counterpulsation. AMI = acute myocardial infarction; APE = acute pulmonary edema; CD = cardiac output; MVR = mitral artery wedge pressure; PM = papillary muscle; SAP (s/d) = systemic arterial pressure (systolic/diastolic).
:
+’
Complete
0
+
: 0
8 +-
l
valve
repkement;
PAWP
= pulmonary
was found to have complete papillary muscle rupture at unsuccessful mitral valve replacement5 Their report suggested that partial muscle rupture might be recognizable before complete rupture. By facilitating recognition of complete or partial papillary muscle rupture, echocardiography may prompt earlier surgical intervention.
1. Niahimura
FIGURE
necrotic,
6. Operative specimen from the fourth patient illustrates the jagged edge of the completely ruptured papillary muscle.
graphic pattern suggestive of disruption of part of the posteromedial papillary muscle in a patient whose condition subsequently deteriorated further; the patient
Sequential Balloon Tech in Angioplasty of Severe Arterial Obstructions DAVID C. LEVIN, MD LAWRENCE M. BOXT, MD RICHARD ABBEN, MD J. DANIEL GARNIC, MD JAMES M. KIRSHENBAUM, DALE ADLER, MD THOMAS SHOOK, MD ETER FRIEDMAN, MD, PkD PETER GANZ, MD
Experienced angiographers have noted that attempts at percutaneous transluminal coronary angioplasty (PTCA) for stenoses of greater than 90% luminal diFrom the Departments of Radiology and Medicine, Brigham and Women’s Hospital-Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115. This study was supported in part by Grant GM-18674 from the U.S. Public Health Service, Bethesda, Maryland. Dr. Ganz is recipient of Clinical Investigator Award t-lb-01045 from the National Heart, Lung, and Blood institute, Bethesda, Maryland. Manwscript received March 29, 1985; revised manuscript received April 1 1985, accepted April 25, 1985.
RA, Sckaff
HU, Chub C, Gereh
BJ, Edwards
pillary muscle rupture complicating acute myocardial i of 17 patients. Am J Cardiol 1983;51:373-377. 2. blintz GS? Victor IMP, Kotler MN, Parry WR, Segal BL. Two-dimenional echocardrographic identification of surgically correctable complications of acute myocardial infarction. Circulation 1981;64:91-96. 3. Erbel R, Schweirer P, Berdos P, Meyer J. Two-dimensional echocar$;;,raphic diagnosis of papillary muscle rupture. Chest 1981;79:595eyman AE. Case records of the Massachusetts General N Engl J Med 1982;307:873-880, 5. Nlshimura RA, Chub C, Tajik AJ. Two dimensional echocardiographic diagnosis of partial papillary muscle rupture. Br Heart J 1982;48:598600. 4. Poh0st
Hospital.
GM,
ameter are associated with higher rates of both technical failure and comp1ications.r Technical failure usually results from inability to pass the balloon catheter through a tiny and irregular residual channel, even though the guide wire had crossed previously. The best chance of passing through such lesions is to use a balloon that, in the deflated state, presents the smallest possible impaction surface (a “low profile”) to the stenosis as it is advanced over the guide wire. On the other hand, the best chance of achieving both primary and long-term patency in PTCA is through use of a relatively large (higher profile) balloon which, when fully inflated, slightly exceeds the diameter of nearby normal segments of the artery. 2p3We describe the clinical results of a sequential balloon technique that accomplishes both of these conflicting goals in the same procedure. PTCA was applied in 74 severely narrowed or totally occluded vessels (45 left anterior descending (LAD) arteries, 14 circumflex arteries, 10 right coronary arteries, 4 coronary bypass grafts and 1 left main coronary artery) after initial successful passage of the guide wire through the obstruction. In most cases, these guide wires were either very flexible, straight-tipped, 300-cm exchange wires (Advanced Cardiovascular Systems-ACS) or steerable wires with slightly curved tips (USCI). A 2.0-mm ACS balloon catheter teas then passed over the wire through the lesion, Once the balloon was in proper position, 2 to 4 inflations were carried out at 120
because of the echocardiographic diagnosis of partial papillary muscle rupture. Severe mitral regurgitation had not been suspected before echocardiography in the third patient with partial rupture. In the fourth patient, the presence of a mechanical defect in the setting of preserved septal and anterior wall motion prompted surgery. Our 4 patients illustrate the spectrum of echocardiographic abnormalities that may be found in patients with complete or partial papillary muscle ‘rupture. Complete papillary muscle rupture may be characterized by 1 or more 2-dimensional findings: abnormal cut-off of 1 papillary muscle; a mobile mass attached to chordae and to the mitral valve, which could simulate a valvular tumor, thrombus or vegetation; and a pattern of mitral prolapse or of a flail mitral leaflet.1-4 Partial papillary muscle rupture has been reported only once previously. Nishimura et al5 described an echocardio-
of Complete and Partial Papillary Muscle Rupture During Acute Myocardial Infarction PATRICIA C. COME, MD MARILYN F. RILEY, BS RONALD WEINTRAUB, MD JAMES P. MORGAN, MD, PhD SHOICHIRO NAKAO, MD
Papillary muscle rupture produces severe mitral regurgitation, which is generally rapidly fatal. Because echocardiography can visualize the papillary muscles and mitral leaflets, it may detect papillary muscle rupture, prompting aggressive medical and surgical therapy. In 4 patients presenting to our hospital in 1983 and 1984, emergency echocardiography was instrumental in diagnosing either complete or partial papillary muscle rupture. Characteristics of the patient population are listed in Table I and pertinent echocardiographic features are illustrated in Figures 1 to 6. In our 4 patients, echocardiography played a pivotal role in diagnosis and therapy. In the first patient, with complete papillary muscle rupture, there was no audible precordial murmur, and the initial pulmonary artery wedge pressure tracing inexplicably failed to reveal large “v” waves. In the second patient, mitral regurgitation was audible, but the patient improved markedly with vasodilator therapy. Emergency surgery was performed From the Charles A. Dana Research Institute and the Harvard-Thorndike Laboratory of the Beth Israel Hospital, Departments of Medicine and Surgery, Beth Israel Hospital and Harvard Medical School, Boston, Massachusetts. Manuscript received December 13, 1984; revised manuscript received May IO, 1985, accepted May 13, 1985.
Apical views of the left ventricle (LV) obtained with slight transducer angulation, from the second patient, in whom partial rupture of the posterior papillary muscle (PM) was confirmed at surgery. There is marked thinning of a localized portion of the inferoposterior wall (area between the 2 unlabeled black arrows). This region of myocardium was akinetic on the 2-dimensional scan. To no definite connection can be seen between the inferoposterior wal; and the papillary muscle. With a slight change in transducer angulation, (bottom), however, a thread-like connection (white arrow) is evident, attaching the papillary muscle to the distal portion of the thinned myocardial region. There was increased echo-reflectivity from the papillary muscles, suggesting fibrosis.
FKXJRE 1. Long-axis diastolic (left) and apical systolic (right) images in the first patient, who had rupture of the posterior papillary muscle confirmed at surgery. In diastole, transection of 1 of the papillary muscles (PM) is seen. During systole, the PM is seen to flail into the left atrium (LA) (right). ANT MV = anterior mitral valve leaflet; AoV = aortic valve; LV = left ventricle; SG = Swan Ganz catheter in the right side of the heart. 787
78%
BRIEF
REPORTS
Fl&JRE 3. Apical 2-dimensional echocardiogram (left) and Doppler echocardiqraphic recording (right) from the second patient reveals holosystolic turbulence (between 2 black arrows) with sample volume placement (unlabeled white arrow) at the back wall of the left atrium (LA). EKG = electrocardiogram; LV = left ventricle; MV = mitral valve.
FIGURE 4. Apical views of the left ventricle (LV) in the third patient, with partial rupture of the posteromedial papillary muscle. Left, a tenuous attachment of the papillary muscle (PM) to the posterior wall is evident (arrowhead). Mlddle and right, dropout of myocardial echoes in the regions where PM attachment would be expected (longer arrows) and eliminate systolic protrusion of part of the PM into and through (short arrow) the mitral valve. LA = left artium.
FIGURE 5. Apical views of the left ventricle (LV) in the fourth patient, with complete papillary muscle (PM) rupture. In diastole (left), the PM was seen to fling freely within the LV. In systole (right), the PM was thrust into the left atrium (LA). The flail motion of the anterior mitral valve (MV) leaflet is not evident in this view. RA = right atrium.
T
TABLE I Age WI &Sex
Pt 1
45F
3” 4
82F 67F 84M
Characteristics
Location AMI Inferior Inferior Inferior
of the Patients Interval (days) from Onset of AMI to G!inical Deterioration
APE
+
21 5 7
0 T
SAP (s/d) (mm Hg) 50/120/80 601” 40/-
Mean PAWP (mm Hg)
Precordial Murmur
30 26 +(2/6) +(3/6)
“28
PM Rupture (l/zn)
MVR
Died
Partial
2 2.9 “T2
Measurements performed after institution of intraaortic balloon counterpulsation. AMI = acute myocardial infarction; APE = acute pulmonary edema; CD = cardiac output; MVR = mitral artery wedge pressure; PM = papillary muscle; SAP (s/d) = systemic arterial pressure (systolic/diastolic).
:
+’
Complete
0
+
: 0
8 +-
l
valve
repkement;
PAWP
= pulmonary
was found to have complete papillary muscle rupture at unsuccessful mitral valve replacement5 Their report suggested that partial muscle rupture might be recognizable before complete rupture. By facilitating recognition of complete or partial papillary muscle rupture, echocardiography may prompt earlier surgical intervention.
1. Niahimura
FIGURE
necrotic,
6. Operative specimen from the fourth patient illustrates the jagged edge of the completely ruptured papillary muscle.
graphic pattern suggestive of disruption of part of the posteromedial papillary muscle in a patient whose condition subsequently deteriorated further; the patient
Sequential Balloon Tech in Angioplasty of Severe Arterial Obstructions DAVID C. LEVIN, MD LAWRENCE M. BOXT, MD RICHARD ABBEN, MD J. DANIEL GARNIC, MD JAMES M. KIRSHENBAUM, DALE ADLER, MD THOMAS SHOOK, MD ETER FRIEDMAN, MD, PkD PETER GANZ, MD
Experienced angiographers have noted that attempts at percutaneous transluminal coronary angioplasty (PTCA) for stenoses of greater than 90% luminal diFrom the Departments of Radiology and Medicine, Brigham and Women’s Hospital-Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115. This study was supported in part by Grant GM-18674 from the U.S. Public Health Service, Bethesda, Maryland. Dr. Ganz is recipient of Clinical Investigator Award t-lb-01045 from the National Heart, Lung, and Blood institute, Bethesda, Maryland. Manwscript received March 29, 1985; revised manuscript received April 1 1985, accepted April 25, 1985.
RA, Sckaff
HU, Chub C, Gereh
BJ, Edwards
pillary muscle rupture complicating acute myocardial i of 17 patients. Am J Cardiol 1983;51:373-377. 2. blintz GS? Victor IMP, Kotler MN, Parry WR, Segal BL. Two-dimenional echocardrographic identification of surgically correctable complications of acute myocardial infarction. Circulation 1981;64:91-96. 3. Erbel R, Schweirer P, Berdos P, Meyer J. Two-dimensional echocar$;;,raphic diagnosis of papillary muscle rupture. Chest 1981;79:595eyman AE. Case records of the Massachusetts General N Engl J Med 1982;307:873-880, 5. Nlshimura RA, Chub C, Tajik AJ. Two dimensional echocardiographic diagnosis of partial papillary muscle rupture. Br Heart J 1982;48:598600. 4. Poh0st
Hospital.
GM,
ameter are associated with higher rates of both technical failure and comp1ications.r Technical failure usually results from inability to pass the balloon catheter through a tiny and irregular residual channel, even though the guide wire had crossed previously. The best chance of passing through such lesions is to use a balloon that, in the deflated state, presents the smallest possible impaction surface (a “low profile”) to the stenosis as it is advanced over the guide wire. On the other hand, the best chance of achieving both primary and long-term patency in PTCA is through use of a relatively large (higher profile) balloon which, when fully inflated, slightly exceeds the diameter of nearby normal segments of the artery. 2p3We describe the clinical results of a sequential balloon technique that accomplishes both of these conflicting goals in the same procedure. PTCA was applied in 74 severely narrowed or totally occluded vessels (45 left anterior descending (LAD) arteries, 14 circumflex arteries, 10 right coronary arteries, 4 coronary bypass grafts and 1 left main coronary artery) after initial successful passage of the guide wire through the obstruction. In most cases, these guide wires were either very flexible, straight-tipped, 300-cm exchange wires (Advanced Cardiovascular Systems-ACS) or steerable wires with slightly curved tips (USCI). A 2.0-mm ACS balloon catheter teas then passed over the wire through the lesion, Once the balloon was in proper position, 2 to 4 inflations were carried out at 120