Ann Thorac Surg 2001;72:1384-1386
© 2001 The Society of Thoracic Surgeons
Case report
Ruptured papillary muscle after mitral valve replacement with preservation of chordae tendineae
Peter Lemke, MDa,
Matthias Roth, MDa,
Bernd Kraus, MDb,
Stephen Hohe, MDa,
Wolf P. Klövekorn, MDa,
Erwin P. Bauer, MDa
a Department of Thoracic and Cardiovascular Surgery, Kerckhoff Clinic Foundation, Bad Nauheim, Germany
b Department of Anesthesiology, Kerckhoff Clinic Foundation, Bad Nauheim, Germany
Accepted for publication September 18, 2000.
Address reprint requests to Dr Roth, Department of Thoracic- and Cardiovascular Surgery, Kerckhoff Foundation, Benekestr 2-8, 61231 Bad Nauheim, Germany
e-mail: matthias.roth{at}kerckhoff.med.uni-giessen.de
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Abstract
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Many cardiac surgeons believe strongly that every effort should be made to preserve the continuity of the mitral anulus, chordae tendineae, and papillary muscles during mitral valve replacement in order to maximize ventricular function and maintain normal ventricular geometry. We treated a patient with spontaneous papillary muscle rupture after mitral valve replacement in whom efforts had been made to preserve continuity of the mitral mechanism.
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Introduction
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Many cardiac surgeons believe strongly that every effort should be made to preserve the continuity of the mitral anulus, chordae tendineae, and papillary muscles during mitral valve replacement in order to maximize ventricular function and maintain normal ventricular geometry. We treated a patient with spontaneous papillary muscle rupture after mitral valve replacement in whom efforts had been made to preserve continuity of the mitral mechanism.
A 33-year-old woman with cardiac failure and atrial fibrillation was admitted to our clinic. Three years previously she had undergone open mitral commissurotomy. She had physical findings typical for mitral insufficiency. Chest roentgenogram showed cardiomegaly, and transesophageal echocardiogram documented severe mitral regurgitation with deformed leaflets suggesting rheumatic heart disease. Mitral valve area was calculated at 1.7 cm2 and the transvalvular gradient was 12 mm Hg. Pulmonary capillary wedge pressure was 29 mm Hg. with V-waves to 55 mm Hg. Mean pulmonary arterial pressure was 37 mm Hg. At operation, thickened leaflets with fused commissures were noted along with thickened and shortened chordae. Several radial incisions were made in the leaflets at the sites of chordal attachments. When necessary to preserve annular integrity, portions of the leaflets with their chordal attachments were sutured to the annulus. None of the valve or subvalvular mechanism was excised. A 33-mm Carbomedics valve (Sulzer Carbomedics Inc, Austin, TX) was then inserted using interrupted sutures.
The early postoperative course was uneventful, and transesophageal echocardiography showed normal valve function. Thirteen days postoperatively, however, repeat transesophageal echocardiography showed a floating structure prolapsing through the aortic valve during systole (Fig 1). Because of the fear of dislocation and embolization, emergency operation was done. The floating structure was the head of the ruptured posterior papillary muscle still attached to the chord. Using cardioscopic guidance (Figs 2 and 3) the structure was viewed through the aortic valve and resected through the mitral prosthesis. The papillary muscle showed evidence of ischemia when examined histologically. The patient had an uneventful recovery and was discharged 51 days after the initial procedure.
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Fig 1. (A) Transesophageal echocardiogram showing papillary muscle head prolapsing through the native aortic valve (50-degree view). (B) Transesophageal echocardiogram showing ruptured papillary muscle head prolapsing through native aortic valve (126-degree view).
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Comment
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Most surgeons consider preservation of the subvalvular structures during mitral valve replacement along with maintenance of the continuity between these structures and the mitral annulus to be important in maximizing left ventricular function [1–3]. There have been reports of disc or poppet entrapment by surgically divided chordal remnants, overhanging knots, long suture ends, and atrial catheters [4]. Spontaneous rupture of a papillary muscle with entrapment of the disc of a Medtronic-Hall prosthesis has been reported twice [5, 6]. In neither instance was there evidence of myocardial infarction. It was speculated that alternation of the left ventricular geometry might have caused rupture of the papillary muscles. Mok and colleagues [7] described hemorrhagic necrosis of the papillary muscle, possibly related to subendocardial ischemia, as the cause of rupture in one case. The case reported here is unusual in that the mitral prosthesis was functioning properly, but the spontaneously ruptured papillary muscle was prolapsing through a normal aortic valve. We believed that urgent operation was necessary to prevent possible embolization.
In our case there was histologic evidence of chronic ischemia of the ruptured papillary muscle. We conclude that rupture was caused by increased tension in the ischemic papillary muscle related to preservation of the chordae [1]. For this reason we recommend that attempts be made to avoid tension on the papillary muscle whenever chordal preservation is done, particularly when the chordal attachments to the valve leaflets are altered.
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Acknowledgments
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The authors thank Dr William A. Gay, Jr, for editing this case report.
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References
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Hetzer R., Drews T., Siniawski H., Komoda T., Hofmeister J., Wenig Y. Preservation of papillary muscles and chordae during mitral valve replacement: possibilities and limitations. J Heart Valve Dis 1995;4(Suppl 2):115-123.
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Williams D.B., Pluth J.R., Orszulak T.A. Extrinsic obstruction of the Björk-Shiley valve in the mitral position. Ann Thorac Surg 1981;32:58-63.[Abstract/Free Full Text]
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Trites P.N., Kiser J.C., Johnson C., Tycast F.J., Gobel F.L. Occlusion of Medtronic Hall mitral valve prosthesis by ruptured papillary muscle and chordae tendinae. J Thorac Cardiovasc Surg 1984;88:301-302.[Abstract]
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Goldenberg M.R., Rozanskii L.T., Degeratu F.T., Berger B.C. Papillary muscle rupture after chordal sparing mitral valve replacement. J Heart Valve Dis 1998;7:590-592.[Medline]
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Mok C.K., Cheung D.L., Chiu C.S., Aung-Khin M. An unusual lethal complication of preservation of chordae tendinae in mitral valve replacement. J Thorac Cardiovasc Surg 1988;95:534-536.[Abstract]
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Abstract
Introduction
