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rchives of Cardiovascular Disease (2014) 107, 340—342

Available online at

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nusual presentation of posterior papillary muscleupture

résentation inhabituelle de rupture de pillier (muscle papillaire) postérieur

Mi Hyoung Moon, Keon Hyun Jo, Hwan Wook Kim ∗

Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary’s Hospital, CatholicUniversity of Korea, 505, Banpo-Dong, Seocho-Gu, Seoul, 137-701, Republic of Korea

Received 18 April 2012; received in revised form 10 May 2012; accepted 10 May 2012Available online 20 February 2013

KEYWORDSPapillary musclerupture;Acute mitralregurgitation;Coronary artery;Acute myocardialinfarction

MOTS CLÉSMuscle papillaire ;Regurgitation mitraleaiguë ;Artère coronaire ;Infarctus aigu dumyocarde

We describe an unusual case of acute myocardial infarction of the non-dominant left cir-cumflex artery, which resulted in posterior papillary muscle rupture. A 50-year-old manwith a history of hypertension presented with acute chest pain, dyspnoea and massivehaemoptysis for 1 day. The patient’s blood pressure was 100/80 mmHg and heart rate was130 beats per minute. Physical examination revealed holosystolic murmur at the apex, andchest X-ray showed pulmonary oedema. Emergent cardiac catheterization showed throm-botic occlusion of an obtuse marginal artery, right dominance, and 70% stenotic lesionon the left anterior descending (LAD) artery. An echocardiogram showed severe mitralregurgitation with suspicious papillary muscle rupture, mild pulmonary hypertension andischaemic insult on the territory of left circumflex artery. An intra-aortic balloon pump wasplaced, and on-site percutaneous coronary intervention on the LAD and obtuse marginalwere done successfully, and the patient was transferred to the operating room for acutemitral regurgitation (Fig. 1). During the operation, complete rupture of the posterome-dial papillary muscle rupture was confirmed, with no other areas of necrosis. The patientunderwent mitral valve replacement with bioprosthesis. The patient’s course was uncom-plicated and he remains in New York Heart Association class II heart failure at 6-monthfollow-up.

Generally, posteromedial papillary muscle receives a single blood supply from the right

coronary artery, and from the left coronary artery in the case of left dominance. In thiscase, however, the patient had right dominance, and a single blood supply of posteromedialpapillary muscle from the left circumflex artery, and occlusion of the obtuse marginalresulted in papillary muscle rupture (Fig. 2).

∗ Corresponding author. Fax: +82 02 594 8644.E-mail address: kimhwanwook@catholic.ac.kr (H.W. Kim).

875-2136/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved.ttp://dx.doi.org/10.1016/j.acvd.2012.05.015

Unusual presentation of posterior papillary muscle rupture 341

Figure 1. A. Preoperative coronary angiography showing acute occlusion in the first obtuse marginal artery (left box, white arrow). Afteron-site percutaneous ballooning, blood flow was restored (middle box, arrowhead). The posterior descending artery was supplied by the

ce (right box). B. Preoperative echocardiogram revealed acute mitral

right coronary artery, thus this coronary system had right dominan regurgitation with suspicious papillary muscle rupture (arrow) and regurimage). C. Preoperative chest X-ray showing pulmonary oedema and intr

gitant jet flow was noted in the colour Doppler image (upper smalla-aortic balloon pump (arrow).

342 M.H. Moon et al.

Figure 2. A. Intraoperative exploration revealed completely ruptured posteromedial papillary muscle (arrow) in the left atrium.B. Histopathological finding of ruptured papillary muscle. Myocytes show contraction band necrosis, an early histological change in acutem tends across the myocytes, and the nuclei are not clearly visible in mosto tion of macrophage (haematoxylin and eosin stain, × 400).

D

Tc

yocardial infarction. Note that a dark contraction band (arrow) exf the cells. The arrowhead indicates myocytolysis with the infiltra

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.