Laparoscopic cholecystectomy delayed by complicated myocardial infarction with papillary muscle rupture, and
Miroslaw Bitner1, Ryszard Jaszewski, Slawomir Jander
1Cardiac Surgery Department, Medical University of Lodz, Poland.
Insights
Gallstone symptoms can mask coronary artery disease, leading to myocardial infarction. A complex mitral valve repair was successfully performed, allowing subsequent gallbladder surgery.
Area of Science:
- Cardiology
- Cardiac Surgery
- Gastroenterology
Background:
- Gallstone disease symptoms can mimic cardiac ischemia, potentially masking underlying coronary artery disease.
- Cholecystectomy is a common procedure, but cardiac comorbidities can complicate management.
Observation:
- A 65-year-old woman presented with gallstones but developed myocardial infarction and pulmonary edema.
- Severe mitral insufficiency due to papillary muscle rupture was identified as a complication of myocardial infarction.
Findings:
- A novel, complex mitral valve repair involving papillary muscle re-implantation and neo-chord placement was successfully performed.
- Coronary artery bypass grafting was also necessary due to significant coronary artery stenosis.
- The patient recovered well from both cardiac surgery and a subsequent laparoscopic cholecystectomy.
Implications:
- Mitral valve repair, rather than replacement, is a viable option for this rare complication.
- Pre-operative screening for coronary artery disease is crucial before cholecystectomy in patients with suggestive symptoms.
- Successful cardiac intervention can enable less invasive procedures like laparoscopic cholecystectomy.
Abstract:
A 65-year-old woman was admitted for laparoscopic cholecystectomy, a method of choice for gallbladder diseases. Symptoms of gallstones are similar to angina pectoris, especially in right coronary artery stenosis. In this case, masked by known symptomatic gallstones, unsuspected coronary artery disease manifested with complicated myocardial infarction and pulmonary edema. The patient survived the acute period, treated pharmacologically. Severe mitral insufficiency caused mainly by ruptured papillary muscle, with left ventricle and atrium enlargement, and right coronary artery stenosis were indications for heart surgery. Repair of this infrequent complication of myocardial infarction is rarely feasible. The complex repair, unique for this cause, is described. During the operation, the head of the ruptured posteromedial papillary muscle was re-implanted, and two neo-chords implanted for prolapsing the A2 mitral valve segment. Annuloplasty with a 29 mm elastic ring accomplished repair. Saphenous bypass graft was applied to the only feasible postero-lateral branch. Although intraoperative echocardiography revealed excellent results, inotropic support, and intra-aortic counterpulsation were necessary for weaning off cardio-pulmonary bypass and low cardiac output treatment. The patient was discharged home on postoperative day 12, with anticoagulant administered for 3 months. As soon as it was no longer required, she underwent laparoscopic cholecystectomy, with no complications. Durable results of both operations performed 5 years ago are confirmed by physical examination and ultrasonography. Complex mitral valve repair, rather than valve replacement, should be considered in similar cases. Possibility of coexistence of coronary artery disease should be considered before cholecystectomy. Good quality repair of cardiac disease allows for laparoscopic cholecystectomy.
