Download Acute Posterior MI with Papillary Muscle Rupture

ACUTE POSTERIOR MYOCARDIAL INFARCTION WITH PAPILLARY
MUSCLE RUPTURE
Rangadham Nagarakanti, MD, Augustine Njoku, MD, Pramilla Subramaniam, MD
Department of Internal Medicine and Section of Cardiology, Louisiana State University Health Sciences
Center, New Orleans, LA
INTRODUCTION
• Rupture of the papillary muscle is one of the rare complications
of posterior wall myocardial infarction (PWMI) associated with
increased mortality (30-95%).
• Earlier cases reported that both anterior and posterior papillary
muscles may rupture, but most commonly posterior, usually from
the occlusion of postero-ventricular branch or distal posterior
descending artery of the dominant right coronary artery. In
patients with acute pulmonary edema with papillary muscle
rupture, no improvement was observed with revascularization
alone.
• We describe a patient with an acute posterior wall MI complicated
by papillary muscle rupture which resulted in sudden death in
spite of prompt resuscitative measures leaving no time for surgery
METHODS
• After the index case was identified, a thorough literature search
was performed using PUBMED and MEDLINE databases. We
have identified 10 articles that met the criteria of Acute posterior
wall myocardial infarction complications and Papillary muscle
rupture. Apporpriate literature was cited in this poster.
CASE DESCRIPTION
DISCUSSION
A 32-year-old male presented with chest pain that occurred at rest
on the day of admission. This chest pain was sub sternal,
pressure like, non-radiating, moderate in intensity, not associated
with diaphoresis or shortness of breath and spontaneously
dissipated after 15 to 30 minutes. He denied tobacco or cocaine
use. His vital signs were stable at presentation. Electrocardiogram
(EKG) revealed a normal sinus rhythm. He had normal heart tones
with a localized 2-3/6 pansystolic murmur at the apex. Aspirin 325
mg daily was administered orally. Initial laboratory studies
including a drug screen were unremarkable. A 2D-echocardiogram
with Doppler demonstrated a prolapsed anterior mitral leaflet with
A directed mitral regurgitation.
B
moderately severe eccentrically
While being evaluated, the patient developed sudden onset severe
substernal chest pain with new ST depressions in the anterior
leads consistent with a posterior myocardial infarction. Emergent
coronary angiography revealed subtotal occlusion of mid to distal
right coronary artery suggestive of intracoronary thrombus and
he underwent a stenting procedure. However, the patient
continued to have chest pain and suddenly developed respiratory
distress with oxygen saturation decreasing to 78% on 2L nasal D
oxygen. Physical exam revealed diffuse bilateral crackles
consistent with acute pulmonary edema, confirmed by
fluoroscopy. Following emergent intubation, he became pulseless
and an intra aortic balloon pump and temporary pacemaker were
placed. The patient did not recover and autopsy demonstrated
the rupture of the papillary muscle with posterior myocardial
infarction.
•Papillary muscle rupture is a rare but generally fatal mechanical
complication of acute myocardial infarction. Papillary muscle
rupture occurs in less than 5% of all transmural infarctions and
conveys a mortality rate of 30-95%.
• Both anterior and posterior papillary muscles may rupture, but
posterior papillary muscle is more common. Posterior papillary
muscle damage usually occurs due to occlusion of distal
posterior descending artery or posterior-ventricular branch of
the dominant right coronary artery.
•In the present case, a recent thrombotic occlusion of a dominant
right coronary artery resulted in myocardial infarction involving
the posterior wall of the left ventricle and the base of the
papillary muscle and in its rupture. The sudden occurrence of
mitral incompetence led to fatal pulmonary edema. In patients
with acute pulmonary edema with mitral valve rupture, no
improvement was observed with revascularization alone.
Emergent repair and replacement of mitral valve, resection of the
akinetic area of ventricle and aorto-coronary bypass in ischemic
patients have been reported to produce some success.
•Prompt diagnosis and aggressive surgical therapy for patients
who develop posterior papillary muscle rupture after myocardial
infarction may be beneficial.
IMAGES & GRAPHS
CONCLUSIONS
• Papillary muscle rupture is one of the rare but generally fatal
mechanical complication of acute myocardial infarction.
• Prompt diagnosis and aggressive surgical therapy for patients
who develop posterior papillary muscle rupture after myocardial
infarction may be beneficial.
REFERENCES
Figure 3. Echocardiogram showing mitral
valve prolapse (anterior leaflet) with
regurgitation
Figure 1. Presentation EKG of the 36 year old male
Figure 2. EKG of same patient with severe substernal chest
pain
Figure 4. Angiogram showing right
coronary artery occlusion
1. Esthes EH, Dalton FM, Entman ML, Dixon HB, Hackel DB. The
anatomy and blood supply of the papillary muscles of the left
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2. De Busk RF, Harrison DC. The clinical spectrum of papillary
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