[Successful Treatment of Blow-out Type Left Ventricular Free Wall Rupture Using Sutureless Technique].

Blow-out type left ventricular free wall rupture is a serious complication of acute myocardial infarction, that carries high hospital mortality rates and poor surgical outcome. We report the case of an 88-year-old woman who developed cardiac tamponade following percutaneous coronary angioplasty for acute myocardial infarction. She was diagnosed with left ventricular free wall rupture, and rupture type was proved to be blow out after median sternotomy. To address this critical condition, we opted for the sutureless technique for its minimally invasive nature and ability to preserve left ventricular function. The patient was discharged from the hospital without any complications 22 days after surgery. Considering favorable, encouraging outcomes of this case, sutureless technique could be regarded as a viable option for blow-out type left ventricular free wall rupture.

[Elective Mitral Valve Repair for Acute Mitral Regurgitation Due to Anterior Papillary Muscle Rupture:Report of a Case].

An 83-year-old woman with congestive heart failure due to severe mitral regurgitation was referred to our department. Because acute coronary syndrome was suspected, the patient underwent emergent coronary artery angiography, which showed 75% stenosis of segment 2 and 90% stenosis of segment 11. Subsequently, segment 11 was treated by percutaneous coronary intervention. Additionally, transesophageal echocardiography findings showed a prolapse of P2 due to papillary muscle rupture. After management of heart failure, a scheduled operation was performed under the diagnosis of acute mitral regurgitation due to papillary muscle rupture. Intraoperative findings demonstrated a rupture of the anterior papillary muscle, prolapse of P2, and no evidence of infection. The patient underwent mitral valve repair with artificial chordae through median sternotomy. Her postoperative course was uneventful.

Mitral valve surgery for acute papillary muscle rupture.

BACKGROUND: Papillary muscle rupture (PMR) is a rare complication of a myocardial infarction. The aim of this study was to review our results of mitral valve surgery for acute PMR. METHODS: Data from patients undergoing emergent mitral valve surgery for acute PMR between 2011 and 2017 at our institution were reviewed. Outcomes included operative morbidity and mortality, mitral valve reoperation, and hospital readmission. RESULTS: A total of 2479 patients underwent mitral valve surgery during the study period including 24 (1.0%) for PMR. Mean age was 62 years, and two (8.3%) patients had prior open-heart surgery. Overall Society of Thoracic Surgeons predicted risk of mortality was 17.5%. Operative mortality was 12.5% (n = 3) with an observed-to-expected mortality ratio of 0.71. There were no strokes, and new onset dialysis was required in two (8.3%) patients. Mean follow-up was 2.40 ± 1.96 years. Three-year mortality, mitral valve reoperation, and readmission rates were 21.1%, 5.0%, and 45.4%. CONCLUSIONS: Expeditious operative intervention for PMR can be associated with acceptable operative and longer-term outcomes.

Clinical presentation and echocardiographic diagnosis of postinfarction papillary muscle rupture: A review of 22 cases.

BACKGROUND: Acute myocardial infarctions (AMI) continue to be common in the United States. Mechanical complications of AMI can lead to cardiogenic shock (CS) and death. The aim of this study was to review the cases of papillary muscle ruptures in the setting of myocardial infarctions at a tertiary care center, with a focus on the clinical presentation and echocardiographic diagnosis. METHODS: This was a retrospective study from January 1, 2000 through December 31, 2014. In all, 22 patients with AMI and papillary muscle rupture (AMI-PMR) who had surgical intervention were identified. RESULTS: The average age was 70 (±11) with 16 (73%) males. Six patients presented with ST-elevation myocardial infarctions (STEMI) and all underwent emergent revascularization with primary percutaneous coronary intervention (PCI) prior to the diagnosis of AMI-PMR. The other 16 patients presented with a non-STEMI. In total, 17 (77%) of the 22 patients were diagnosed with an AMI-PMR within 7 days from their onset of symptoms. In all, 12 patients (55%) had anterolateral papillary muscle ruptures (ALPMR), and the other 10 had posteromedial papillary muscle ruptures (PMPMR). Ruptures were complete in 10 patients (45%). Patients presented with pulmonary edema early (<7 days) more commonly than late (>14 days). Transthoracic echocardiography was able to demonstrate severe mitral regurgitation in 86% and a definitive or suggestive diagnosis in 93%. All 22 patients survived to operative management, and the overall in-hospital mortality rate was 9%. CONCLUSION: In conclusion, ischemic papillary muscle ruptures continue to occur, but with prompt diagnosis by echocardiography and rapid surgical management, the mortality rate continues to decline.

[Emergency Mitral Valvoplasty for Papillary Muscle Rupture].

We experienced 2 emergency surgical cases of severe mitral valve regurgitation due to papillary muscle rupture. Case 1:a 69-year-old man presented with respiratory and cardiac failure due to mitral regurgitation. He had no history of myocardial infarction. Mitral valve repair with artificial cords was performed. The papillary muscle of the anterior leaflet was ruptured. The postoperative course was uneventful. Case 2:a 80-year-old man came to our hospital with cardiac arrest. Emergency coronary intervention was performed to the right coronary and intraaortic balloon pumping was inserted. However his condition remained unstable. Severe mitral regurgitation was found by teansesophageal echo cardiography, and he underwent emergency mitral valve repair and single coronary bypass grafting. His cardiac function recovered quickly, but severe brain damage remained.

Intramyocardial Dissecting Hematoma after Acute Myocardial Infarction-Echocardiographic Features and Clinical Outcome.

OBJECTIVES: Intramyocardial dissecting hematoma (IDH) after acute myocardial infarction (MI) is a rare form of subacute cardiac rupture and hence management uncertainties. The objective of this study was to describe the clinical course of a small series of IDH patients and to review the available evidence for managing similar cases. METHODS: Eight IDH patients from our center had echocardiographic, coronary angiographic and clinical outcome data reviewed. PubMed was also searched for IDH following MI. Cases were divided into three groups and compared according to the dissection location. RESULTS: In our 8 patients, 3 had septal, 1 right ventricular (RV), and 4 left ventricular (LV) dissection. Five were medically treated and 3 surgically repaired. Reviewing the literature revealed 68 IDH patients, of mean age 66 ± 10 years, 43 males. The percentage of IDH involving the LV free wall, septal, and RV free wall were 47%, 26.5%, and 26.5%, respectively. In the cohort as a whole, mortality was not different between surgically and medically treated patients (33.3% vs. 54.3%, P = 0.08), neither based on the IDH location (P = 0.49). While surgical and medical treatment of the LV free wall (20.0% vs. 40.9%, P = 0.25) and septal (46.2% vs. 60.0%, P = 0.60) were not different, surgical repair of RV free wall had significantly better survival (30.0% vs. 87.5%, P = 0.015). The LVEF (P = 0.82), mitral regurgitation (P = 0.49) failed to predict mortality. CONCLUSION: While survival following medical and surgical treatment of LV IDH is not different, patients with RV free wall dissection benefit significantly from surgical repair.

A Case of Post Myocardial Infarction Papillary Muscle Rupture.

Papillary muscle rupture is a rare, life-threatening post myocardial infarction mechanical complication. Without surgical intervention, prognosis is very poor. Clinicians need to recognize this complication early, as prompt therapy is crucial. We present a case of inferior ST elevation myocardial infarction complicated by posteromedial papillary muscle rupture resulting in severe acute mitral regurgitation (flail anterior mitral leaflet), acute pulmonary edema and cardiogenic shock. In our patient, a new mitral regurgitation murmur suggested this mechanical complication. Complete disruption of papillary muscle was visualized by transesophageal echocardiography. This case illustrates the importance of good physical examination for early diagnosis of papillary muscle rupture, so that life-saving treatment can be administered without delay.

Lateral left ventricular wall rupture following acute myocardial infarction: pathophysiological interpretation by multimodality imaging approach.

Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. In the present case, 76 hours following the intervention, LVWR was observed likely due to a small infarction at the lateral left ventricular wall possibly due to the marginal lesion. Our patient refused surgery and was followed clinically. Eighteen months later, real time three-dimensional echocardiography showed a pseudoaneurysm.

[Valve plasty for mitral regurgitation caused by partial papillary muscle rupture after acute myocardial infarction;report of a case].

A 58-year-old woman was referred to our hospital because of acute myocardial infarction. Percutaneous coronary intervention for total occlusion of the circumflex coronary artery was performed successfully. However, she had heart failure that was gradually getting worse because of mitral valve regurgitation. Therefore, we performed valve plasty using the resection and suture method for mitral regurgitation caused by partial papillary muscle rupture. Her postoperative course was uneventful, and she was discharged on postoperative day 26. At 6 months after the operation, her functional status was New York Heart Association(NYHA) class I and transthoracic echocardiogram showed no mitral regurgitation( MR).

Real time three-dimensional transesophageal echocardiography in partial posteromedial papillary muscle rupture.

A 60-year-old hypertensive male with non-ST segment elevation myocardial infarction had a hyperdynamic LV with mild posterior leaflet mitral valve prolapse without significant regurgitation on transthoracic echocardiogram. Two-dimensional (2D) TEE showed severe mitral regurgitation with prolapse of P2 and P3 scallops. Posteromedial papillary muscle rupture was suspected. Three-dimensional (3D) TEE demonstrated severely prolapsing P2 and P3 valve scallops with a clear view of the partially ruptured posteromedial papillary muscle. Patient underwent emergency coronary bypass and mitral valve replacement. Surgical pathology of papillary muscle confirmed coagulative necrosis. 3D TEE was superior in identifying the partial posteromedial papillary muscle rupture.

Surgical treatment of ventricular septal defect following myocardial infarction: a case report.

Ventricular septal defect after myocardial infarction is a rare but often life-threatening mechanical complication. The keys of management are a prompt diagnosis of ventricular septal defect and an aggressive approach to stabilize patient's hemodynamics. Invasive monitoring, judicious use of inotropes and vasodilators, and an intra-aortic balloon pump are recommended for the optimal support of patient's hemodynamics. The best results are achieved if optimally medically managed patients survive at least 4 weeks before elective surgery necessary for scar formation in a friable infarcted tissue. We report a case of acute myocardial infarction complicated by the rupture of ventricular septum. Instead of attempting an immediate surgical closure of ventricular septal defect, the postponed surgery was successfully performed 3 weeks after the occurrence of ventricular septal defect. Preoperatively, clinical and hemodynamic conditions of the patient were maintained stable with the support of an intra-aortic balloon pump and inotropes.

Factors associated with in-hospital mortality from free wall rupture after acute myocardial infarction.

BACKGROUND: Free wall rupture is a fatal and emergency complication of acute myocardial infarction. The factors associated with in-hospital mortality from free wall rupture remain unclear. OBJECTIVES: To investigate the factors associated with in-hospital mortality from free wall rupture. METHODS: We performed a single-center, retrospective study. We enrolled 111 consecutive patients with free wall rupture following acute myocardial infarction who were admitted to Fuwai Hospital from January 2005 to May 2021. The primary endpoint was in-hospital death. Clinical characteristics, laboratory data, and treatment modalities associated with in-hospital mortality were analyzed. RESULTS: Eighty-seven of the 111 study participants died in hospital. Multivariate Cox regression analysis showed that pericardiocentesis (hazard ratio [HR] 0.296, 95% confidence interval [CI] 0.094-0.929, p = 0.037), pericardial effusion at admission (HR 0.083, 95% CI 0.025-0.269, p<0.001), time interval between acute myocardial infarction and free wall rupture (HR 0.670, 95% CI 0.598-0.753, p<0.001), and previous myocardial infarction (HR 0.046, 95% CI 0.010-0.208, p<0.001) were independently associated with in-hospital mortality. CONCLUSIONS: Pericardiocentesis, pericardial effusion at admission, the acute myocardial infarction to free wall rupture time, and previous myocardial infarction are associated with a lower rate of in-hospital mortality from free wall rupture after acute myocardial infarction.

Coronary sinus thrombosis as a complication of myocardial infarction-associated ventricular wall rupture: an unusual cause of collapse.

Coronary sinus thrombosis is a rare phenomenon, most commonly occurring following invasive cardiac procedures. Spontaneous thrombosis is extremely rare and little is known about the natural history or optimal management. We present a case of coronary sinus thrombosis occurring in the context of myocardial infarction with concealed ventricular wall rupture.

[Successful repair of left ventricular free wall rupture with repeated mydriasis and loss of light reflex].

A 73-year-old woman was transferred to our hospital because of loss of consciousness. Cardiac catheterization showed a left ventricular free wall rupture (LVFWR) due to acute myocardial infarction at the posterolateral region. Shortly after cardiac catheterization, she lost her consciousness again and went into cardiogenic shock. Repeated mydriasis and loss of light reflex was recognized during establishment of cardiopulmonary bypass. Direct suture closure using equine pericardial strips and 4-0 polypropylene mattress sutures was performed under cardiac arrest. The suture site was covered with TachoComb and fibrin glue. Post-cardiac arrest brain injury was prevented by postoperative mild hypothermia. Surgical repair of LVFWR should be performed even when the signs of severe cerebral ischemia are apparent.

[Mechanical complications of myocardial infarction]. / Complications mécaniques de l'infarctus du myocarde.

Despite a marked reduction in mortality after myocardial infarction during the last decades thanks to heart monitoring and early reperfusion, there remains a significant rate of in-hospital mortality. This is a consequence of refractory ventricular dysfunction in most cases, or mechanical complications of myocardial infarction in the remaining cases. Mechanical complications include septal rupture with ventricular septal defect, tamponnade following rupture of the left ventricular free wall, and acute mitral regurgitation due to papillary muscle infarction and rupture. Although these complications are rare, their prognosis is very poor. An early detection of clinical signs of mechanical complications is crucial to urgently precise the diagnosis by echocardiography and subsequently plan the most appropriate medico-surgical management.

Transcatheter Mitral Valve Edge-to-Edge Repair with the New MitraClip XTR System for Acute Mitral Regurgitation Caused by Papillary Muscle Rupture.

Treatment of patients presenting with cardiogenic shock due to acute mitral regurgitation related to papillary muscle rupture poses significant challenges, owing to the high risk associated with conventional surgery. We hereby report successful transcatheter mitral valve edge-to-edge repair with the new Mitraclip XTR device (Abbott Vascular, Santa Clara, CA) in a patient with acute myocardial infarction and cardiogenic shock. Although surgical intervention remains the standard of care, the new MitraClip XTR system offers a novel treatment option for patients with papillary muscle rupture by overcoming the anatomic challenges often seen in this pathology.

Cardiogenic shock.

Cardiogenic shock is the most common cause of death in patients hospitalized with acute myocardial infarction and is associated with a poor prognosis. More than 75% of cases are due to extensive left ventricular infarction and ventricular failure. Other causes include right ventricular infarction and papillary muscle rupture with acute severe mitral regurgitation. Activation of neurohormonal systems and the systemic inflammatory response worsens shock. To improve outcomes, cardiogenic shock needs to be recognized early in its course and its cause needs to be diagnosed rapidly. Treatment strategies using intra-aortic balloon counterpulsation and emergency revascularization by percutaneous coronary interventions or coronary bypass surgery have been shown to improve outcomes. To decrease the incidence of cardiogenic shock, public education regarding early presentation to hospital in the course of acute chest pain is important. Emergency medical transport systems may need to take patients with complicated acute myocardial infarction to hospitals with the capability to perform urgent revascularization.

[Mitral valve repair with concomitant coronary bypass for partial rupture of an anterior papillary muscle].

We report a case of severe mitral regurgitation due to partial rupture of an anterior papillary muscle. A 63-year-old man was admitted to a hospital with heart failure. He was treated with diuretic agents effectively. Echocardiography demonstrated severe mitral regurgitation with prolapse of posterior leaflet and small mass-like structure on the prolapsed segment that was diagnosed the thickened leaflet. Coronary angiography revealed total occlusion of left anterior descending artery (LAD) filled with good collateral from right posterior descending artery and severe diffuse stenosis of circumflex artery (Cx). The patient underwent surgery on the 33rd day after admission with heart failure. At surgery, we recognized rupture of one of the heads of anterior papillary muscle that was entangled in chordae of the prolapsed segment. Mitral valve repair and coronary revascularization to LAD and Cx was successfully performed. His postoperative course was uneventful, and he was discharged on the 28th postoperative day.