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Ann Thorac Surg 2003;76:269-271
© 2003 The Society of Thoracic Surgeons
a Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
b Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
Accepted for publication December 23, 2002.
* Address reprint requests to Dr Joseph H. Gorman, 3400 Spruce St, 6 Silverstein Pavilion, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
e-mail: gormanj{at}uphs.upenn.edu
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Abstract |
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Introduction |
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Some would consider the octogenarian presenting in cardiogenic shock secondary to mitral regurgitation caused by a ruptured papillary muscle or primary chord to be a futile clinical situation [3]. This may be particularly true in the current era of health care cost containment. We present two such cases with successful outcomes.
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At approximately 12 hours from the onset of symptoms, the patient was taken to the operating room. Cardiopulmonary bypass was instituted, and the patient was cooled to 28°C. Myocardial protection consisted of an initial dose of antegrade and retrograde cold blood cardioplegia and continuous low flow retrograde cold blood. The mitral valve was exposed through a standard left atriotomy. The atrium was small, and the leaflets and chordae were structurally normal. The posterior papillary muscle had ruptured near its attachment to the left ventricle. The mitral valve was replaced with a 27-mm St. Jude prosthesis using standard techniques to maintain annular continuity with the remaining anterior papillary muscle. The patient was weaned from cardiopulmonary bypass on the first attempt with support of the intraaortic balloon pump and moderate doses of milrinone and epinephrine.
Postoperatively the patient was extubated and the intraaortic balloon pump was removed within 24 postoperative hours. The milrinone and epinephrine were weaned over a 3-day period. The patient was transferred from the intensive care unit on postoperative day 3. He was started on warfarin anticoagulation, beta-blockers, and angiotensin-converting enzyme inhibitors, and he was in sufficiently good condition to be discharged home on postoperative day 6. Eight weeks postoperatively the patient returned to his daily activities and was living at home with his 81-year-old spouse.
Patient 2
Two weeks before admission, an 88-year-old woman with a known history of mild mitral stenosis and MR secondary to rheumatic disease presented to an outside hospital. Her chief complaint was chest tightness and shortness of breath after minimal exertion. Chest roentgenogram at that time revealed mild pulmonary edema. Electrocardiogram showed her usual chronic atrial fibrillation and no signs of ischemia. Transthoracic echocardiogram revealed the presence of mild MR and mitral stenosis along with normal left ventricular function. She was treated as an outpatient with diuretics for congestive heart failure.
On the day of admission she again presented to an outside hospital with severe shortness of breath, hypotension, and a creatinine of 2.5 mg/dL (base line, 1.0 mg/dL). She was transferred to our hospital.
On arrival, physical examination revealed a thin, elderly woman in severe respiratory distress with an arterial oxygen saturation of 90%, breathing 100% supplemental oxygen. Her systolic blood pressure was 70 mm Hg and her heart rate was 125 beats per minute. Her extremities were cold and cyanotic. Electrocardiogram showed no obvious signs of myocardial ischemia. She was intubated and started on an infusion of epinephrine (4 ug/min).
Transesophageal echocardiogram revealed normal left ventricular function with no obvious wall motion abnormality, but with severe MR. The leaflets and chordae were mildly thickened. A portion of both leaflets were flail, which was thought to be consistent with a ruptured posterior papillary muscle tip. Cardiac catheterization was notable for anLVEDP of 35 mm Hg and normal coronary arteries. An intraaortic balloon pump was placed during this procedure. The patient was taken to the operating room for emergency mitral valve replacement using the technique previously described for patient 1. Surgical exposure revealed severe rheumatic degeneration of the valve with ruptured chordae of both anterior and posterior leaflets in the region of the posterior commissure.
The intraaortic balloon pump was removed on the first postoperative day. On postoperative day 2 the patient was extubated. On postoperative day 5 she was well enough to leave the intensive care unit. She was started on warfarin and discharged home on postoperative day 10.
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Comment |
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Three separate studies report 30-day operative mortality for mitral valve replacement in the setting of a ruptured papillary muscle, ranging from 19% to 27% [4, 6, 7]. The average age of patients in these studies was 61, 64, and 68 years. In addition, theSociety of Thoracic Surgeons database reports an operative mortality of 31.9% and 45.4% for patients undergoing combined mitral valve replacement and coronary artery bypass grafting in emergency and salvage situations, respectively [8]. Factors that significantly reduce survival in these cases include elevated serum creatinine, preoperative inotropic support, and preoperative mechanical ventilation. Both of our patients exhibited all three factors.
The second patient was included in this report because her clinical situation and echocardiographic findings at presentation were typical of a ruptured papillary muscle tip. In fact, this was the working diagnosis before the cardiac catheterization. Most patients with a ruptured papillary muscle have suffered a relatively small infarction and are in rapid decline because of the acute torrential MR, not because of the infarction itself. Our first patient’s situation demonstrates this; this patient clearly had his infarction 4 days before his presentation, remained very active for the following several days, and then acutely decompensated when his valve became incompetent.
At presentation, both patients were dying from acute severe MR, and therefore similar conclusions can be drawn from both patients. Despite arriving to our institution within 12 hours of the onset of symptoms, both patients were in the early stages of multiple system organ failure. This fact illustrates how quickly elderly patients decompensate under the stress of acute torrential MR.
This report demonstrates that surgery for acute severe MR with cardiogenic shock can be successfully performed in the octogenarian. Immediate evaluation and treatment is critical. Further clinical studies and reports are warranted to extend this knowledge base.
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This article has been cited by other articles:
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  W. Y. Szeto, R. C. Gorman, J. H. Gorman III, and M. A. Acker Ischemic Mitral Regurgitation Card. Surg. Adult, January 1, 2008; 3(2008): 785 - 802. [Full Text]
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