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J Thorac Cardiovasc Surg 2006;132:428-430
© 2006 The American Association for Thoracic Surgery
Brief Communication |
First Department of Cardiology and Department of Cardiosurgery, Medical University of Gdansk, Gdansk, Poland
Received for publication April 10, 2006; accepted for publication April 20, 2006. * Address for reprints: Marcin Fijalkowski, MD, First Department of Cardiology and Department of Cardiosurgery, Medical University of Gdansk, ul. Debinki 7, 80-952 Gdansk, Poland (Email: mfijalkowski{at}amg.gda.pl).
The incidence and natural history of papillary muscle rupture occurring after chord-sparing mitral valve replacement for ischemic mitral insufficiency are unknown. A case in which this complication occurred after chord-sparing mitral valve replacement is described.
Clinical Summary
A 59-year-old man was admitted to our institution with acute heart failure symptoms and chest discomfort lasting for 3 days. The electrocardiogram showed sinus tachycardia (115 beats/min) and pathologic Q waves in the II, III, and aVF leads. The serum concentrations of creatine kinase MB and troponin I were significantly elevated. A chest radiograph revealed pulmonary edema. Two-dimensional transthoracic echocardiography showed akinesia of inferior and posterior walls and severe mitral regurgitation caused by posterior leaflet restriction (vena contracta 7 mm). Coronary angiography showed occluded right and circumflex coronary arteries and a critically narrowed left anterior descending coronary artery.
On the basis of these findings, mitral valve surgery and coronary artery bypass grafting were recommended. Treatment with intra-aortic balloon pump support was started, without significant improvement. Emergency cardiosurgery was performed because of the patient's unstable condition. The mitral valve was replaced with a 29-mm Medtronic Advantage prosthesis (Medtronic, Inc, Minneapolis, Minn) placed in antianatomic position with preservation of the posterior leaflet (ring annuloplasty was not successful). Coronary artery revascularization was done in the same operation.
The early postoperative course was uneventful. At the end of the second week of hospitalization, hypotension and pulmonary edema occurred, associated with a decrease in the loudness of prosthetic valve sounds. Transesophageal echocardiography revealed that one of the prosthetic disks did not move during the cardiac cycle and stayed in a semiopen position (Figure 1), leading to severe regurgitation. There was no echocardiographic evidence of prosthetic valve thrombosis, but additional echo was seen close to the entrapped disk (Figure 1). Reoperation revealed that the head of the anteroseptal papillary muscle attached to its chordae tendineae had ruptured and wedged between one of the disks and prosthetic valve ring, resulting in the jamming of the disk in a semiopen position (Figure 2). The mitral valve Medtronic Advantage bileaflet prosthesis was replaced with a 27-mm On-X valve prosthesis (Medical Carbon Research Institute, LLC, Austin, Tex). This time, the posterior leaflet and subvalvular apparatus were surgically removed. The postoperative course was complicated by ischemic stroke.
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Papillary muscle rupture is a complication that occurs in a minority of cases of acute myocardial infarction.
1
The questions raised by this case concern the incidence of postoperative papillary muscle rupture after chord-sparing mitral valve replacement for ischemic mitral regurgitation, as well as the consequences of a flail papillary muscle segment in the left ventricle, especially its interference with the prosthetic valve function. There have been reports of valve prosthetic disk entrapment by surgically divided chordal remnants, overhanging knots, long suture ends, and atrial catheters.
2
Spontaneous rupture of papillary muscle with entrapment of the tilting disk of a Medtronic Hall prosthesis has been reported only twice, in both cases causing death.
3,4
Lemke and colleagues
5
described a case of spontaneous rupture of papillary muscle after mitral valve replacement, with normal function of mitral prosthesis and floating ruptured papillary muscle prolapsing through the normal aortic valve.
To our knowledge, there are no reports on disk entrapment of the bileaflet mechanical mitral valve prosthesis caused by spontaneous papillary muscle rupture with preserved chordae tendineae. The case reported here is unusual in that the one of the disks of a bileaflet prosthetic valve was jammed in a semiopen position while the other disk function remained normal. It is common knowledge that preservation of the subvalvular structures—the continuity of the mitral annulus, chordae tendineae, and papillary muscles—during mitral valve replacement is important in maximizing ventricular function and maintaining normal ventricular geometry. Mok and associates
4
described hemorrhagic necrosis of the papillary muscle, possibly related to subendocardial ischemia, as the cause of rupture in 1 case after mitral valve replacement. It is likely in our case that rupture of the head of papillary muscle was due to stress on the ischemic papillary muscle by increased tension related to preservation of the chordae tendineae when the posterior leaflet was oversewn into the base of the prosthetic mitral valve. There is also the possibility that the change in the left ventricular geometry after the operation may have led to increased stress on the chordae tendineae. For those reasons, every effort should be made to avoid excessive tension on the papillary muscle whenever chordal preservation is done, particulary when the papillary muscle could be ischemic. In view of the current widespread use of chord-preserving techniques in ischemic mitral valve replacement, the problem presented in this report is likely to be encountered again in the future.
References
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