ECHO 2013 / Acute Coronary Syndromes Echo in the Assessment of Complications

Papillary Muscle Rupture

Anatomy and blood supply of the papillary muscles

– Anterolateral papillary muscle

dual blood supply from the left anterior descending artery and by marginal tributaries from the circumflex artery

– Posteromedial papillary muscle

Single blood supply from the contributors to the posterior descending artery.

Papillary Muscle Rupture

Acute complete rupture of the large common trunk

– Results in torrential MR and hemodynamic compromise.

Partial rupture of the large common trunk or complete rupture of one of the multiple heads of the papillary muscle

–Better tolerated than complete rupture of a major trunk

–Potential for additional or more extensive rupture

– Unpredictable rapid decompensation

Papillary Muscle Rupture

Clinical presentation and diagnosis

–PMR entails <5% of ischemic MR

–Incidence ~ 1% of all AMIs and accounts for 5% of the mortality following AMI

More common with inferior wall MI

Nearly twice the mortality seen in those with a ventricular septal defect after an acute infarct

–Usually occurring 2-7 days post AMI

–Clinical presentation

Acute rapid hemodynamic deterioration

Pulmonary edema/cardiogenic shock

Severe dyspnea with raised venous pressure and rales throughout the lung fields

Murmur of mitral regurgitation may be present but may be inaudible because of the rapid equalization of left atrial and left ventricular pressures

Acute rupture of the ventricular septum may present in a similar manner but patients may not have the severe dyspnea and orthopnea seen in patients with severe mitral regurgitation: a loud systolic murmur and thrill are almost always present.

Papillary Muscle Rupture

Diagnostic test of choice: Echocardiography

– TTE

Flail mitral valve leaflet with systolic prolapse into the left atrium

Mobile mass (papillary muscle) attached to the chordae tendinae and to the mitral valve

Abnormal cutoff of one PM

–Diagnosis suspected by the presence of hemodynamic compromise concomitant with preserved systolic function

Papillary Muscle Rupture

TTE Color: eccentric jet, area poorly-imaged (equilibration of TEE Color Doppler

LA and LV pressures)

Ventricular Septal Rupture

1% of all acute MI in past, with thrombolytics, < 0.2%

5% of fatal MI’s

Only with transmural MI Risk factors:

–First infarction

–Advanced age (> 65 yo)

–Hypertension

– Female gender

–Other: no prior history of angina (no collaterals), single vessel infarct

Presentation:

–Median presentation within 24 hours (but up to 2 weeks)

–Recurrent chest pain, dyspnea, sudden hypotension/shock

– New harsh systolic murmur (50% of pts)

TTE

Echo in VSR

TTE detects in 40-70% of pts

–Contrast increases to 86-95%

–TEE 100% sensitivity and specificity

Echo characteristics:

– Increased RA pressure: bowing of IAS to left with IVC plethora

–Color Doppler size of defect correlates with surgical size

–Using peak VSD gradient to estimate of RVSp may be inaccurate

Poor-Prognostic signs

– Posterior VSR (associated with RV dysfunction)

– Cardiogenic shock

Echo in VSR: ICE

Echo in VSR: TEE

Acute Ventricular Septal Rupture

The long-term survival rate in the surgically treated group was

–48% after one year

–32% after five years.

In patients 75 years (n = 7) the one-year survival rate was 0% (compared with 52% in patients with an age < 75 years).

– Consider the use of a transcatheter closure device

Highest one-year survival rate among the surgically treated group was found in patients

–< 65 years (n = 12) as compared with patients with an age of 65 to 74 years (n = 26) (83% and

38%, respectively, p < 0.05)

20% residual VSD postsurgical repair

Poulsen SH et al. Ann Thor Surg 2008;85:591-1596