P1470 Rare cause of papillary muscle rupture post cardiac surgery

• Published in: European heart journal cardiovascular imaging Vol. 21; no. Supplement_1
• Main Authors: Lopez Rodriguez, E, Calvo Iglesias, F, Blanco Gonzalez, E, Varela Martinez, M A, Legarra Calderon, J J
• Format: Journal Article
• Language: English
• Published: Oxford University Press 01-01-2020
• ISSN: 2047-2404; 2047-2412
• DOI: 10.1093/ehjci/jez319.896

Abstract
Introduction
Papillary muscle rupture (PMR) secondary to mitral valve repair surgery is a rare complication in the postoperative period of cardiac surgery
Purpose
We present a case of PMR with fatal outcome after mitral valve repair with a rigid ring secondary to accidental ligature of the circumflex artery (CA).
Methods
An 83-year-old male referred for valvular surgery for symptomatic mitral regurgitation (MR). In the last echocardiography LVEF was mildly depressed (45-50%), severe organic MR (A2 chord rupture), functional TR, and moderate degenerative AR. With these findings and together with a normal coronary angiography, he was presenting at the Heart Team for triple valvular surgery. The procedure consisted of implanting aortic biological prosthesis, mitral and tricuspid annuloplasty. During the pump output, he presented ventricular arrhythmias, but in the intraoperative transesophageal echocardiography (TEE) a good result was demonstrated. At 24h postoperatively the patient enters arrhythmic storm, ischemia data appear on ECG (ST-segment depression of V1-V3 and DI-aVL) and elevation of markers of myocardial damage (TnIc 450 ng/mL), which point to complication postsurgical cardiology is contacted for urgent echocardiography.
Results
The echocardiography showed a massive MI due to postero-medial PMR, inferior and inferolateral akinesia and severe biventricular dysfunction. With these findings and with the suspicion of accidental ligation of CA during the implantation of the mitral annulus, urgent catheterization is considered. Given the evolution of the ischemic event and the delicate hemodynamic situation, this option is discarded, so that angiographic confirmation is not achieved. Finally, the patient undergoes cardiac revision surgery as a last option. After performing sternotomy, cardiac rupture at a lower level is evidenced, patch closure is attempted but due to tissue friability it is not achieved and the patient dies in the surgical act.
Conclusion
RMP after mitral valve surgery is a very rare complication. The majority of published cases are related to increased tension forces after mitral replacement with preservation of the subvalvular apparatus. Our case would be the first described of MPR secondary to accidental ligation of AC after mitral annuloplasty.