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Ann Thorac Surg 2001;72:257-259
© 2001 The Society of Thoracic Surgeons

Case report

Traumatic papillary muscle rupture

Timothy A. Simmers, MD, PhDa, Huub W.J. Meijburg, MD, PhDa, Aart Brutel de la Rivière, MD, PhDb a Department of Cardiology, Heart-Lung Institute, University Medical Center, Utrecht, The Netherlands
b Department of Cardiothoracic Surgery, Heart-Lung Institute, University Medical Center, Utrecht, The Netherlands

Accepted for publication May 25, 2000.

Address reprint requests to Dr Simmers, Department of Cardiology, Heart-Lung Institute, University Medical Center, E03.406, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
e-mail: h.l.i.lon{at}hli.azu.nl


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Papillary muscle rupture caused by blunt chest trauma is a relatively rare cause of mitral incompetence. To date only 25 cases of surgically corrected posttraumatic mitral regurgitation have been reported, of which only eight resulted from rupture of the anterolateral papillary muscle.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Blunt chest trauma is a rare cause of acute mitral regurgitation. Sudden deceleration or compression of the heart with subsequent damage to the closed atrioventricular valve or subvalvular apparatus is responsible; patients are thus generally motor vehicle accident victims. Presentation, diagnosis, and treatment of this potentially fatal complication are illustrated by the following case.

A previously healthy 22-year-old man was admitted to the emergency room of the University Medical Center at Utrecht, The Netherlands, after a head-on collision between his car and a truck. He had exited his vehicle and was conscious on arrival of paramedic personnel but lost consciousness en route to our facility. Examination found crush injury of the left leg, a dislocated hip, fractured acetabulum and left humerus, cuts and abrasions to the head, and a ruptured spleen. There was no evidence of trauma to the chest. Despite emergency operation, including laparotomy for the injuries described and adequate fluid resuscitation, the patient became increasingly hypotensive. Atrial fibrillation occurred while ventilation pressures increased, with radiographic findings consistent with pulmonary edema. Postoperative examination found a grade 2/6 blowing systolic murmer at the apex of the heart. Transoesophageal echocardiography showed complete avulsion of the anterolateral papillary muscle causing massive mitral regurgitation (Fig 1A and B). Immediate implantation of a prosthetic mitral valve was done. Rehabilitation was protracted, but he was discharged in good health 2 months after the accident.



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  		Fig 1. (A) Transesophageal echocardiographic image showing complete avulsion of the anterolateral papillary muscle (PM). (B) Transesophageal echocardiographic image also demonstrating flail anterior mitral valve leaflet (arrow) and posterior leaflet (arrowhead).

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Although myocardial infarction is a well-recognized cause of papillary muscle rupture and mitral regurgitation, blunt chest trauma is a rarely reported cause. Parmley and coworkers [1] described only 24 instances of papillary muscle rupture in 546 autopsy cases of nonpenetrating trauma to the chest. Only 25 cases of successful surgical repair of posttraumatic mitral incompetence have been reported [2–23] (Table 1), only eight of which were caused by complete avulsion of the anterolateral papillary muscle, as in the present case [12–15, 16, 21, 23]. Sudden deceleration and transfer of kinetic energy to the victim’s chest is the most common cause of valvular injury. The atrioventricular valves, when closed in systole, are most susceptible to damage by deceleration or compression of the heart and blood column. Absence of external evidence of chest trauma does not exclude significant valvular or vascular injury, as the present case demonstrates. It is not surprising that most occurrences of such trauma result from motor vehicle accidents. Symptoms are invariably due to hemodynamic deterioration or pulmonary edema. The reported interval between injury and surgical intervention is highly variable, from hours to decades. In the present case, complete avulsion of the anterolateral papillary muscle caused massive mitral incompetence, pulmonary edema, and rapid hemodynamic deterioration. Similarly, in many patients reported to have required mitral valve operations within 2 weeks of their trauma, there was complete rupture of either [7, 15, 17, 23] or both [21] papillary muscles. Although the nature of the damage to the valve and subvalvular structures dictates the best mode of repair, there is no consenus in the literature as to the preferred treatment of a given lesion in this group of patients. Mitral valve replacement is the most common treatment reported. Although reconstruction of the subvalvular apparatus might be preferable, the most expeditious procedure is sometimes necessary. Because of the extremely compromised circulation and poor condition of the patient described, reconstruction of the valve was not attempted and a prosthetic valve was implanted. Transoesophageal echocardiography was invaluable in the diagnosis of papillary muscle rupture.


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  		Table 1. Summary of Reported Cases of Surgically Corrected Mitral Insufficiency From Blunt Chest Trauma

 

   References
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 Abstract
 Introduction
 Comment
 References
 
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