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Published on: May 19, 2020
Papillary muscle rupture without severe mitral regurgitation following percutaneous balloon mitral commissurotomy: a
Pierre Rossignon1, Sofia Morra1, Quentin de Hemptinne1
1Department of Cardiology, CHU Saint-Pierre, Université Libre de Bruxelles, Rue aux Laines 105, 1000 Brussels, Belgium.
Background:
Percutaneous transvenous mitral commissurotomy (PTMC) is the first-line therapy of clinically significant rheumatic mitral stenosis. While the procedure is generally safe, new onset or aggravation of mitral regurgitation (MR) may occur, mainly due to commissural splitting and, less frequently, to leaflet tear and chordal rupture. Papillary muscle rupture (PMR) is exceedingly rare in this setting.
Case Summary:
A 74-year-old woman with a history of aortic valve replacement and prior rheumatic mitral commissurotomy presented for worsening exercise intolerance and exertional dyspnoea. Transthoracic echocardiography showed a mean pressure gradient of 10 mmHg and a mitral valve area of 1.0 cm², consistent with clinically significant mitral stenosis. Subsequent PTMC was complicated by anterolateral PMR. However, the resulting MR was unexpectedly only of mild-to-moderate severity. Because of residual mitral stenosis and persisting symptoms, surgical mechanical mitral valve replacement and tricuspid annuloplasty were performed 6 weeks after PTMC. Papillary muscle rupture was confirmed during surgery.
Discussion:
We herein describe the occurrence of PMR induced by PTMC; the resulting MR was unexpectedly of mild-to-moderate severity, as a result of extensive rheumatic lesions limiting valve mobility. This case challenges the dogma according to which PMR invariably leads to severe MR. This might not be necessarily the case when it occurs following PTMC.
Insights
Papillary muscle rupture (PMR) during percutaneous transvenous mitral commissurotomy (PTMC) for mitral stenosis can cause mild-to-moderate mitral regurgitation (MR). This rare complication challenges the assumption that PMR always leads to severe MR.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Percutaneous transvenous mitral commissurotomy (PTMC) is a primary treatment for severe rheumatic mitral stenosis.
- Mitral regurgitation (MR) can occur post-PTMC due to leaflet or chordal damage, but papillary muscle rupture (PMR) is exceptionally rare.
- PMR is a severe complication that typically results in significant mitral regurgitation.
Observation:
- A 74-year-old female with prior valve interventions presented with worsening dyspnea due to mitral stenosis.
- PTMC was performed, but complicated by anterolateral papillary muscle rupture (PMR).
- Despite the PMR, the resulting mitral regurgitation (MR) was unexpectedly mild-to-moderate.
Findings:
- This case demonstrates that PMR following PTMC can result in less severe MR than typically expected.
- Extensive rheumatic valve disease with limited mobility may have contributed to the less severe MR.
- The patient underwent successful valve replacement and tricuspid annuloplasty due to residual stenosis and symptoms.
Implications:
- PMR following PTMC does not invariably lead to severe mitral regurgitation.
- The extent of rheumatic disease may influence the severity of MR after PMR.
- This finding may alter the management approach for PTMC complications.
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