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. 2013 Dec;44(6):1063-9.
doi: 10.1093/ejcts/ezt150. Epub 2013 Mar 21.

Mitral valve repair for post-myocardial infarction papillary muscle rupture

Wobbe Bouma  1 , Inez J Wijdh-den Hamer, Theo J Klinkenberg, Michiel Kuijpers, Aanke Bijleveld, Iwan C C van der Horst, Michiel E Erasmus, Joseph H Gorman 3rd, Robert C Gorman, Massimo A Mariani
Affiliations

Mitral valve repair for post-myocardial infarction papillary muscle rupture

Wobbe Bouma et al. Eur J Cardiothorac Surg. 2013 Dec.

Abstract

Objectives: Papillary muscle rupture (PMR) is a rare, but serious mechanical complication of myocardial infarction (MI). Although mitral valve replacement is usually the preferred treatment for this condition, mitral valve repair may offer an improved outcome. In this study, we sought to determine the outcome of mitral valve repair for post-MI PMR and to provide a systematic review of the literature on this topic.

Methods: Between January 1990 and December 2010, 9 consecutive patients (mean age 63.5 ± 14.2 years) underwent mitral valve repair for partial post-MI PMR. Clinical data, echocardiographic data, catheterization data and surgical reports were reviewed. Follow-up was obtained in December of 2012 and it was complete; the mean follow-up was 8.7 ± 6.1 (range 0.2-18.8 years).

Results: Intraoperative and in-hospital mortality were 0%. Intraoperative repair failure rate was 11.1% (n = 1). Freedom from Grade 3+ or 4+ mitral regurgitation and from reoperation at 1, 5, 10 and 15 years was 87.5 ± 11.7%. Estimated 1-, 5-, 10- and 15-year survival rates were 100, 83.3 ± 15.2, 66.7 ± 19.2 and 44.4 ± 22.2%, respectively. There were 3 late deaths, and 2 were cardiac-related. All late survivors were in New York Heart Association Class I or II. No predictors of long-term survival could be identified.

Conclusions: Mitral valve repair for partial or incomplete post-MI PMR is reliable and provides good short- and long-term results, provided established repair techniques are used and adjacent tissue is not friable. PMR type and adjacent tissue quality ultimately determine the feasibility and durability of repair.

Keywords: Mitral regurgitation; Mitral valve repair; Myocardial infarction; Outcome; Papillary muscle.

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Figures

Figure 1:
Figure 1:
Papillary muscle anatomy and rupture. (A) Left atrial, superior view of the mitral valve. Note that the chordae from both papillary muscles are attached to the AMVL, PMVL and the corresponding commissure. (B–D) Segmentation of the papillary muscles (ALPM or PMPM). (B) A single uniform unit. (C) Groove with two apexes (with or without muscular bridges). (D) Complete separation with 2 heads. The anatomy of the PMPM, which is the usual site of ischaemic injury, is usually more complex and it is frequently subdivided into several heads. (E–G) Three different forms of PMR (ALPM or PMPM). (E) Complete or total PMR. (F) Incomplete PMR. (G) Partial PMR. Seperate PM heads support specific portions of the mitral valve. Therefore, in the case of a partial rupture, the extent of leaflet prolapse varies according to the territory supplied by the ischaemic head. Total rupture of a PM generally produces a prolapse of the entire hemivalve. AC: anterior commissure; ALPM: anterolateral papillary muscle; AMVL: anterior mitral valve leaflet; PC: posterior commissure; PMPM: posteromedian papillary muscle; PMVL: posterior mitral valve leaflet.
Figure 2:
Figure 2:
Intraoperative photograph of partial PMPM rupture and papillary muscle repair. (A) Acute partial PMPM rupture after inferoposterior MI. (B) PMPM repair with a pledget-reinforced polytetrafluorethylene (PTFE) suture. PMPMR: posteromedian PMR; PR-PTFE suture: pledget-reinforced polytetrafluorethylene suture.
Figure 3:
Figure 3:
Kaplan–Meier actuarial survival after mitral valve repair (n = 8) for post-MI PMR. Pts: patients; +: censored.
See this image and copyright information in PMC

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