Transesophageal echocardiography in identifying papillary muscle rupture complicating acute myocardial infarction: case report and review of literature

doi:10.21203/rs.3.rs-2061843/v1

Papillary muscle rupture (PMR) is a rare but potentially life-threatening complication of acute myocardial infarction (AMI). Optimal outcomes require swift diagnosis and prompt surgical intervention, and transesophageal echocardiography (TEE) plays an important role in the process. We present a missed diagnosis case of PMR in the initial procedure and review the literature, focusing on the features of diagnosis, which may be beneficial in clinical management.

Papillary muscles

Rupture

Myocardial infarction

Echocardiography

Transesophageal

Papillary muscle rupture is an uncommon cardiac emergency that usually occurs 2–7 days after AMI, with an incidence of 0.029%[1, 2]. Without timely diagnosis and effective intervention, it may be associated with a poor prognosis. The hospital mortality approached 80% in the first week with medical treatment alone[2]. TEE has a higher diagnostic sensitivity than transthoracic echocardiography (TTE). In this report, a case of PMR following non-ST elevation myocardial infarction (NSTEMI) was presented and diagnosed by TEE. Furthermore, we review the literature and discuss the features of PMR, which may be helpful for appropriate management.

A 71-year-old man with a significant history of NSTEMI and severe mitral regurgitation (MR) over two months was referred to our hospital for heart failure symptoms. Two months ago, the patient presented to the local hospital with chest discomfort. The initial TTE revealed a dilated left heart with a normal left ventricular function. Unfortunately, he developed acute stethalgia on the fourth day of his hospitalization. The second TTE showed hypokinesis of the inferior wall, flail of the posterior mitral valve leaflet and severe MR. A diagnosis of NSTEMI was confirmed based on an electrocardiogram (ECG), TTE, and increased cardiac troponin I. The distal left circumflex artery was found to be occluded by coronary angiography. However, his condition did not improve after drug therapy. He was admitted with heart failure symptoms.

On physical examination, a 3/6 systolic murmur was audible near the apex. Except for an elevation of NT-ProBNP level at 1120 pg/ml, the other laboratory tests were unremarkable. Sinus tachycardia and modest ST-segment depression were recorded on the ECG (Fig. 1). A repeated TTE showed hypokinesis of the posterior and inferior walls, severe eccentric MR secondary to P2 scallops prolapse and chordae tendinea rupture (Fig. 2A-B and Videos 1 in the Date Supplement). TEE was performed to detect more anatomical details, which clearly revealed a moveable mass attached to the posterior mitral valve via the flail chordae and entering the left atrium during systole (Fig. 2C and Videos 2 in the Date Supplement). PMR with P2 prolapse was confirmed. Three-dimensional TEE provided a diagnostic view of the ruptured papillary muscle (PM) head (Fig. 2D). As a result, a diagnosis of PMR complicating AMI was established, with a distally occluded left circumflex artery as the culprit.

The patient underwent mitral valve replacement and concomitant coronary artery bypass grafting. Intraoperatively, a complete rupture of the posteromedial PM was identified (Fig. 2E-F). The postoperative TEE showed normal prosthetic valve function. The patient was discharged seven days after surgery. This study was approved by an institutional review committee, and the patient gave written informed consent.

PMR is a rare but fatal complication of AMI that can lead to severe mitral regurgitation, acute pulmonary edema, and cardiogenic shock[3, 4]. The incidence of PMR complicating AMI was reported to be 0.05–0.26%, while hospital mortality remains high, ranging from 10–40%, especially in elderly patients[5]. Surgical intervention is a recommended therapeutic strategy in the current guideline[6]. According to research, the mortality rate was significantly higher (60.6%) for nonoperative management than for surgical intervention (27.9%)[7]. Therefore, prompt diagnosis and timely surgical treatment are critical to achieving the best possible outcomes.

Echocardiography is the primary imaging modality for PMR, and TTE is widely perceived as an initial diagnostic tool of PMR with a diagnostic sensitivity of 65%-85%[8]. Direct visualization of the ruptured PM is the most important evidence for a definitive diagnosis, such as the ruptured head prolapsed into the left atrium. However, TTE fails to uncover this feature in approximately one-third of patients, even by experienced doctors[9]. The mitral apparatus is a posterior structure, and TEE has shown superiority in identifying and localizing PMR by providing better imaging of the submitral valve apparatus[10]. To our knowledge, TEE has a diagnostic accuracy of 95–100%[11], making it an excellent alternative for patients with suspected PMR. The patient underwent TTE scans twice in our hospital, none of which revealed the indications for PMR. Finally, TEE was employed to make the definitive diagnosis. TEE has a higher diagnostic sensitivity for PMR, but it is not appropriate for a screening tool. Therefore, TTE was used as a guide to assist in screening, and TEE was used to examine selected patients who had some significant indications.

To identify the characteristics of PMR and provide more additional diagnosis information, which may facilitate accurate diagnosis and timely treatment, we searched PubMed for articles about PMR caused by AMI that were published between January 1, 2012, and April 30,2022, and only articles describing the site of prolapse were retained. Finally, a total of 22 case reports involving 24 patients were eligible and included in our analysis (Table 1). Posteromedial PMR was found in 58% of patients (n = 14) while anterolateral PMR was found in 42% of patients (n = 10) in our database. According to the literature, posteromedial papillary muscle rupture occurs 6–12 times more frequently than anterolateral papillary muscle rupture[3]. This is because the posteromedial papillary muscle (PM) receives an independent circulatory supply from either the right coronary artery or the left circumflex artery, whereas the anterolateral PM has a dual blood supply from both the left anterior descending artery and the left circumflex artery[12]. We also found that the P2 segment was the most frequent prolapsing segment in patients with PMR post-AMI (42%, 10/24 patients), followed by the A2 segment (33%, 8/24 patients). We think this is tightly linked to the anatomy; each PM offers chordae to the ipsilateral half of both mitral leaflets, and the A2/P2 region receives chordae from both sets of PMs so that rupture of either PM may affect either the A2 or P2 segment [13, 14]. Based on the literature and our experience, indications for the use of TEE in AMI patients include (1) regional ventricular wall motion abnormality, particularly inferior wall motion abnormalities; (2) new onset of severe mitral regurgitation, especially eccentric jet; and (3) mitral valve prolapse, particularly P2 or A2, alone or together with other segments.

Table 1

Clinical and echocardiographic characteristics and management of PMR post AMI
Sr.no.	References	Age	Sex	PM	Method of diagnosis	The sites of prolapse	surgery
1	Nakamae et al.[18]	85	F	anterolateral PM	TEE	P2	MVR
2	Budra et al.[19]	69 74 54	M F F	posteromedial PM posteromedial PM posteromedial PM	Autopsy TEE TEE	Case1:A2 Case2:A3 Case3:P3	MVr MVr MVr
3	Corna et al.[20]	65	F	anterolateral PM	TTE	A1、A2、P1	MVR
4	Hayek et al.[21]	75	F	posteromedial PM	TEE	A2、A3	Transcatheter MVr
5	Labrada et al.[22]	52	M	posteromedial PM	TEE	P2	MVR
6	Theodoropoulos et al[23]	78	M	anterolateral PM	TEE	A1	Died before surgery
7	Tachibana et al.[24]	83	F	anterolateral PM	TEE	P2	MVr
8	Kunkel et al.[25]	57	M	posteromedial PM	TEE	P2、P3	MVR
9	Tyler et al.[26]	51	M	anterolateral PM	TTE	P2	Transcatheter MVr
10	Sliman et al.[27]	66	M	anterolateral PM	TEE	A1、A2、P1	MVR
11	Masuda et al.[28]	70	M	posteromedial PM	/	A3	MVr
12	Castro et al.[29]	76	F	posteromedial PM	TTE	A2	MVR
13	Papadopoulos et al.[30]	85	F	anterolateral PM	TEE	A1、A2、P1	Transcatheter MVr
14	Thompson et al.[31]	54	M	posteromedial PM	TEE	P2	MVr
15	de Cannière et al.[32]	51	M	posteromedial PM	TTE	P3	MVR
16	Tsujimoto et al.[33]	66	F	posteromedial PM	TEE	P2	MVR
17	Lee et al.[34]	75	M	anterolateral PM	TEE	lateral commissure、A1、P1	MVr
18	Selder et al.[35]	65	F	posteromedial PM	TEE	P2	MVR
19	Bitner et al.[36]	65	F	posteromedial PM	TTE + TEE	P3、A3、medial commissure 、A2	MVr
20	Havins et al.[37]	60	M	posteromedial PM	TEE	P2、P3	MVR
21	Vieira et al.[38]	59	M	anterolateral PM	TTE	P1、P2	MVr
22	Stefanovski et al.[39]	63	M	anterolateral PM	TTE	A1、A2	MVR
F, female; M, male; PM, papillary muscle; TTE, transthoracic echocardiography; TEE, transesophageal echocardiography; MVR, mitral valve replacement; MVr, mitral valve repair.

Surgery is the only curative therapeutic approach for PMR and remains a challenge. The optimal surgical approach and timing of PMR are still under debate[15]. Accurate anatomic diagnosis by echocardiography facilitates the surgeon in deciding whether to repair or replace the mitral valve. Mitral valve replacement (MVR) is frequently performed due to its reliability and durability, particularly when the rupture is complete [5]. However, mitral valve repair (MVr) may be an alternative treatment in PMR patients. MVr has a lower operative mortality rate, shorter hospitalization time and similar incidence of short-term postoperative complications to MVR[16]. For patients who are not candidates for surgery, transcatheter edge-to-edge mitral valve repair is a novel treatment option, and TEE is essential in determining anatomic eligibility for transcatheter repair[17].

In summary, it is necessary to suggest underlying candidates for further TEE examination. These indications may facilitate more effective clinical decision-making and medical management. The case highlights the importance of TEE for diagnosis in selected patients and may be beneficial in management.

PMR Papillary muscle rupture

PM Papillary muscle

AMI Acute myocardial infarction

NSTEMI Non-ST elevation myocardial infarction

TTE Transthoracic echocardiography

TEE Transesophageal echocardiography

MR Severe mitral regurgitation

MVR Mitral valve replacement

MVr Mitral valve repair

Author contributions Manuscript writing: PLL, WWQ and FLL; collected and analyzed the data: PLL, WWQ, and LBB; Manuscript editing: FLL and XMX. All authors read and approved the final manuscript.

Funding None.

Conflict of interest The authors declare that they have no conflict of interest.

Ethical approval This manuscript was approved by the departmental ethics committee.

Informed consent Informed consent was obtained from the patient before enrollment in the study.

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No competing interests reported.

VideoS1.avi
Video1: Transthoracic echocardiographic images of the ruptured “chordae tendinea”.
VideoS2.avi
Video2: Transesophageal echocardiographic revealed a moveable mass attached to the posterior mitral valve via the flail chordae and entering the left atrium during systole.

Transesophageal echocardiography in identifying papillary muscle rupture complicating acute myocardial infarction: case report and review of literature

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Abstract

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Introduction

Case Report

Discussion

Conclusion

Abbreviations

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References

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