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Archives of cardiovascular diseases
Volume 107, n° 5
pages 340-342 (mai 2014)
Doi : 10.1016/j.acvd.2012.05.015
Received : 18 April 2012 ;  accepted : 10 May 2012
Unusual presentation of posterior papillary muscle rupture
Présentation inhabituelle de rupture de pillier (muscle papillaire) postérieur
 

Mi Hyoung Moon, Keon Hyun Jo, Hwan Wook Kim
Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, Catholic University of Korea, 505, Banpo-Dong, Seocho-Gu, Seoul, 137-701, Republic of Korea 

Corresponding author. Fax: +82 02 594 8644.

Keywords : Papillary muscle rupture, Acute mitral regurgitation, Coronary artery, Acute myocardial infarction

Mots clés : Muscle papillaire, Regurgitation mitrale aiguë, Artère coronaire, Infarctus aigu du myocarde


We describe an unusual case of acute myocardial infarction of the non-dominant left circumflex artery, which resulted in posterior papillary muscle rupture. A 50-year-old man with a history of hypertension presented with acute chest pain, dyspnoea and massive haemoptysis for 1day. The patient's blood pressure was 100/80mmHg and heart rate was 130 beats per minute. Physical examination revealed holosystolic murmur at the apex, and chest X-ray showed pulmonary oedema. Emergent cardiac catheterization showed thrombotic occlusion of an obtuse marginal artery, right dominance, and 70% stenotic lesion on the left anterior descending (LAD) artery. An echocardiogram showed severe mitral regurgitation with suspicious papillary muscle rupture, mild pulmonary hypertension and ischaemic insult on the territory of left circumflex artery. An intra-aortic balloon pump was placed, and on-site percutaneous coronary intervention on the LAD and obtuse marginal were done successfully, and the patient was transferred to the operating room for acute mitral regurgitation (Figure 1). During the operation, complete rupture of the posteromedial papillary muscle rupture was confirmed, with no other areas of necrosis. The patient underwent mitral valve replacement with bioprosthesis. The patient's course was uncomplicated and he remains in New York Heart Association class II heart failure at 6-month follow-up.



Figure 1


Figure 1. 

A. Preoperative coronary angiography showing acute occlusion in the first obtuse marginal artery (left box, white arrow). After on-site percutaneous ballooning, blood flow was restored (middle box, arrowhead). The posterior descending artery was supplied by the right coronary artery, thus this coronary system had right dominance (right box). B. Preoperative echocardiogram revealed acute mitral regurgitation with suspicious papillary muscle rupture (arrow) and regurgitant jet flow was noted in the colour Doppler image (upper small image). C. Preoperative chest X-ray showing pulmonary oedema and intra-aortic balloon pump (arrow).

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Generally, posteromedial papillary muscle receives a single blood supply from the right coronary artery, and from the left coronary artery in the case of left dominance. In this case, however, the patient had right dominance, and a single blood supply of posteromedial papillary muscle from the left circumflex artery, and occlusion of the obtuse marginal resulted in papillary muscle rupture (Figure 2).



Figure 2


Figure 2. 

A. Intraoperative exploration revealed completely ruptured posteromedial papillary muscle (arrow) in the left atrium. B. Histopathological finding of ruptured papillary muscle. Myocytes show contraction band necrosis, an early histological change in acute myocardial infarction. Note that a dark contraction band (arrow) extends across the myocytes, and the nuclei are not clearly visible in most of the cells. The arrowhead indicates myocytolysis with the infiltration of macrophage (haematoxylin and eosin stain, ×400).

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Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.



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