A case of hypervirulent K1-ST23 Klebsiella pneumoniae endocarditis and papillary muscle rupture secondary to multiple site abscesses.

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.

Echocardiography in the Recognition and Management of Mechanical Complications of Acute Myocardial Infarction.

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. 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.

Acute mitral regurgitation with and without acute heart failure.

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.

Transcatheter edge-to-edge mitral valve repair for post-myocardial infarction papillary muscle rupture and acute heart failure: A systematic review.

Papillary muscle rupture (PMR) is a rare complication of acute myocardial infarction (AMI) associated with high mortality and morbidity. Surgery is the gold-standard treatment for these patients, but it is burdened by a high perioperative risk due to hemodynamic instability. Mitral transcatheter edge-to-edge repair (M-TEER) was reported to be safe and effective in unstable patients with significant mitral regurgitation. However, data in patients with post-AMI PMR are limited to a few case reports. In this review, we summarized all data available regarding percutaneous treatment of post-AMI PMR. These results show that M-TEER is safe and effective in this setting with low in-hospital mortality and complications and high rate of significant mitral regurgitation reduction.

Extracorporeal life support in mitral papillary muscle rupture: Outcome of multicenter study.

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.

ECPELLA as the bridge to surgery in patients with cardiogenic shock due to post-infarct papillary muscle rupture: management of mechanical circulatory support during operation.

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.

Mechanical Complications of Myocardial Infarction.

In this retrospective observational study, we have examined the incidence, characteristics, and treatment of serious myocardial infarction (MI) -associated mechanical complications (MCs) occurring in Japanese patients in this era of percutaneous coronary intervention (PCI), focusing on frailty, nutrition, and clinical implication of surgery. Included were 883 patients who, having suffered an MI, had been admitted to Nihon University Hospital between January 2013 and April 2020. Fifteen (1.70%) of these patients had suffered a potentially catastrophic MC-ventricular free wall rupture (VFWR, n = 8), ventricular septal rupture (VSR, n = 6), or papillary muscle rupture (PMR, n = 1). Factors associated with the MCs were age, poor nutritional status, a high Killip class, delayed diagnosis of MI, a high lactate concentration, a low thrombolysis in myocardial infarction flow grade, and single-vessel disease. Thirty-day mortality among MC patients was 60% (9/15): 87.5% associated with VFWR, 33.3% associated with VSR and 0% associated with PMR. On adjusted multivariate analysis, occurrence of an MC was independently associated with 30-day mortality. Despite a high surgical risk (EuroSCORE II: 11.8 ± 4.7) with less frailty, 30-day mortality was lower among patients whose MC was treated surgically than among those whose MC was treated conservatively (40.0% versus 100.0%, respectively; P = 0.044).Our data suggest that surgical intervention can save patients with a life-threatening MI-associated MC and should be considered, if they are not particularly frail.

Perioperative Extracorporeal Membrane Oxygenation for Refractory Cardiopulmonary Failure Complicating Papillary Muscle Rupture.

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.

Left thoracotomy approach for left ventricular pseudoaneurysm due to myocardial infarction after mitral valve replacement for papillary muscle rupture.

A 59-year-old man with acute mitral regurgitation due to papillary muscle rupture after myocardial infarction was admitted to our hospital. He underwent emergent mitral valve replacement with a mechanical valve by median sternotomy. Although postoperative echocardiography showed no sign of a ventricular aneurysm, echocardiography performed 5 weeks after the surgery showed enlarging left ventricular pseudoaneurysm of the inferior to the posterior cardiac wall. He underwent dacron patch closure of the orifice by fifth intercostal left thoracotomy. The postoperative course was uneventful and he was discharged on postoperative day 10. The patient was successfully treated for two life-threatening complications occurring subsequently after myocardial infarction.

Degenerative Mitral Regurgitation: Assessment, Physical Examination, and Imaging.

PURPOSE OF REVIEW: In this review, we provide a comprehensive approach to assess degenerative mitral regurgitation. RECENT FINDINGS: In the evaluation of MR, it is important to differentiate between primary (degenerative/organic) MR in which an intrinsic mitral valve lesion(s) is responsible for the occurrence of MR and secondary (functional) MR where the mitral valve is structurally normal, but alterations of the left ventricular geometry cause deterioration of the MV apparatus. Advanced imaging modalities, foremost two-dimensional and three-dimensional echocardiography, are essential for this determination. In the evaluation of degenerative MR, the exact mechanism, the extent of the disease, associated valve lesions, the grade of mitral regurgitation severity, and hemodynamic consequences require careful assessment in order to provide patients with appropriate monitoring and treatment.

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.

Papillary muscle rupture following acute myocardial infarction: Anatomic, echocardiographic, and surgical insights.

Papillary muscle (PM) rupture is a rare complication of acute myocardial infarction which carries an excessive mortality rate. Optimal outcomes require rapid diagnosis and prompt surgical referral, and in this regard, echocardiography plays a crucial role. Comprehensive echocardiographic examination of the patient with PM rupture consists of identification of the ruptured PM segment, visualization of flail mitral valve segment(s), evaluation of mitral regurgitation severity, and assessment of left ventricular systolic function. This article discusses anatomic and echocardiographic features as well as the surgical management of PM rupture.

Papillary muscle rupture after myocardial infarction during left ventricular assist device support.

We report a rare case of papillary muscle rupture due to myocardial infarction during left ventricular assist device support. A 69-year-old woman with cardiogenic shock due to acute myocardial infarction requiring venoarterial extracorporeal membrane oxygenation support was transferred for further surgical intervention. Six days after the event, extracorporeal membrane oxygenation was decannulated, and an extracorporeal left ventricular assist device was implanted. On postoperative day 11, she suffered from sudden onset hypoxia due to pulmonary edema. Transesophageal echocardiography showed new onset severe mitral regurgitation. No further surgical intervention was performed according to the family's wishes, and she passed away on the 22nd postoperative day. Autopsy findings revealed papillary muscle rupture. Although the left ventricle is unloaded by the left ventricular assist device, papillary muscle rupture should be recognized as a possible complication after myocardial infarction.

An unusual presentation of ischaemic mitral regurgitation as P2 prolapse.

A 54-year-old gentleman presented with pulmonary oedema secondary to anterolateral papillary muscle (PPM) rupture and acute mitral regurgitation subsequent to myocardial ischaemia (MI). Angiography revealed complete occlusion of the first obtuse marginal (OM1) branch of the circumflex coronary artery and a 70% occlusion of the left anterior descending (LAD) coronary artery. Operatively, unusual anatomy was noted; an accessory head was attached superiorly to the anterior lateral PPM. This gave rise to chordae that were subsequently attached to the posterior second (P2) scallop. Additionally, the P2 scallop was deficient in chordae from the posteromedial PPM, thus, loss of this accessory head led to severe mitral regurgitation. We review the PPM anatomy and pathological context of PPM rupture and ischaemic mitral regurgitation.

Papillary Muscle Rupture Following Non-ST-Elevation Myocardial Infarction: A Case Report.

Papillary muscle rupture is a serious mechanical complication of acute myocardial infarction typically seen within 5-7 days following transmural ST-elevation myocardial infarction. The incidence of papillary muscle rupture has markedly decreased in the modern era due to improved diagnosis and early coronary revascularization of ST-elevation myocardial infarction. As a result, papillary muscle rupture is increasingly seen following non-ST-elevation myocardial infarction where both diagnosis and revascularization can be delayed. In this report, we describe two cases of papillary muscle rupture following delayed presentation of non-ST-elevation myocardial infarction and delayed recognition of papillary muscle rupture.

Successful percutaneous mitral valve repair with the MitraClip system of acute mitral regurgitation due to papillary muscle rupture as complication of acute myocardial infarction.

Percutaneous mitral valve repair with the MitraClip is a new promising therapeutic option for symptomatic severe mitral regurgitation (MR). Acute myocardial infarction (MI) is a well recognized cause of papillary muscle rupture (PMR). If PMR is untreated, the prognosis is poor and the mortality could be as high as 80% during the first week of post MI. For patients with PMR, the standard therapy for MR is open surgical repair or replacement. However, in our case, percutaneous mitral valve repair with the MitraClip was chosen technique because of the metastatic colon cancer. We report the case of a 60-year-old woman who underwent successful percutaneous mitral valve repair with the MitraClip system for the treatment of acute MI complicated by PMR.

A flail anterior tricuspid leaflet secondary to anteroposterior papillary muscle rupture in a neonate.

This article is a summary of a case of a neonate who presented with tricuspid valve insufficiency associated with papillary muscle rupture but, however, showed no signs of cardiac failure. The transthoracic three-dimensional echocardiographic findings in this case are described in detail herein.