Case report
Anterolateral papillary muscle rupture after intervention of the right coronary artery
Rotura do músculo papilar anterolateral após intervenção na artéria coronária direita
Liam Morris
, Anand Desai, Nuri Ilker Akkus
Corresponding author
Division of Cardiology, LSU Health Sciences Center, Shreveport, LA, United States
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Herein, we present a rare case of an isolated right coronary artery (RCA) lesion resulting in anterolateral papillary muscle rupture and concomitant right ventricular (RV) infarction.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 78-year-old white male with a history of hypertension, hyperlipidemia, cerebrovascular accident, right carotid endarterectomy (three years previously) and chronic stage 5 kidney disease, presented to the emergency department with retrosternal chest pressure starting two days prior to admission. The patient described the pain as dull in nature, radiating to the left arm. His history was positive for dyspnea on minimal exertion since the onset of symptoms; however there was no associated orthopnea or paroxysmal nocturnal dyspnea. His social history was negative for smoking, alcohol or illicit drug use. His home medications included aspirin, lisinopril, pravastatin, ferrous sulfate, calcium acetate, ergocalciferol and calcium carbonate.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical exam, heart rate was 102 beats/min and blood pressure was 103/87 mmHg. The rest of the clinical exam was unremarkable with normal S1, S2 and no murmur. The ECG revealed sinus rhythm, left axis deviation, non-specific intraventricular conduction block and ST-T wave abnormalities suggestive of inferior ischemia. Laboratory tests revealed an elevated troponin I level of 11.8 ng/ml. A two-dimensional (2D) echocardiogram showed severe inferior wall hypokinesis, with moderately reduced left ventricular systolic function and estimated ejection fraction of 35–40%, with no significant mitral regurgitation (MR). The patient was urgently taken to the cardiac catheterization laboratory and was found to have a 99% RCA lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), with no significant lesions in the other vessels. Successful percutaneous coronary intervention with stenting of the RCA was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>); the patient was admitted to the telemetry floor for close monitoring, and continued on intravenous normal saline to prevent contrast-induced nephropathy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The next morning, the patient complained of diffuse weakness and lethargy. He was found to be hypotensive (systolic blood pressure 60 mmHg), tachycardic (136 beats/min) and tachypneic (24 cycles/min). Physical examination revealed elevated jugular venous pressure, a new 2/6 holosystolic murmur heard best over the apex, radiating to the axilla, and scattered bibasilar crackles on pulmonary auscultation. The ECG showed sinus tachycardia, with inferior ST elevations suggestive of injury. Postprocedural troponin was also elevated at 114.0 ng/ml. The chest X-ray revealed changes consistent with pulmonary edema. Repeat 2D echocardiography revealed anterolateral papillary muscle rupture with severe eccentric mitral regurgitation (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>), and evidence of right ventricular hypokinesis. He was started on norepinephrine and taken urgently to the catheterization laboratory, where the previously placed stent was found to be patent. Right heart catheterization revealed elevated right-sided pressures with pulmonary artery pressure of 55/25 mmHg, RV pressure of 47/21 mmHg and right atrial pressure of 20 mmHg, and an intra-aortic balloon pump was placed. He was started on a low-dose milrinone infusion due to RV dysfunction and low cardiac output, and the cardiothoracic surgery department was consulted for emergent surgery. Due to RV infarction and improved hemodynamic status with vasopressors and inotropes the surgery was delayed for 2–3 days by the surgical team. However the patient suffered cardiorespiratory failure on day 2, requiring intubation with mechanical ventilation, and expired after cardiac arrest on day 3.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We present an unusual case of anterolateral papillary muscle rupture due to an isolated RCA lesion, complicated by a right ventricular infarction. Papillary muscle rupture usually occurs two to seven days after the infarction,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,4</span></a> and in our patient occurred on day 3 (he complained of symptoms lasting two days prior to admission). Furthermore, coronary angiography revealed a large RCA with an overwhelming right predominance. The left circumflex artery was small in comparison, and showed only mild disease, which could explain the anterolateral papillary muscle rupture, as its major blood supply was from the RCA. We believe a periprocedural MI also contributed to this catastrophe, as shown by a significant elevation in cardiac biomarkers post-procedure, coupled with findings of RV infarction on imaging studies. Although an early conservative approach was adopted, due to the presence of an RV infarction and a favorable response to vasopressors and inotropic agents, the severity of the MR and the acute nature of its onset contributed to the patient's demise.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, anterolateral papillary muscle rupture from an isolated right coronary artery lesion is extremely rare, and when associated with right ventricular infarction, can be fatal. Echocardiography remains the key to diagnosing this devastating mechanical complication of an acute MI.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Early surgery still remains the best possible management option,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,4</span></a> however data on right ventricular infarctions complicating the above is limited.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Ethical disclosure</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Protection of human and animal subjects</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Confidentiality of data</span><p id="par1035" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Right to privacy and informed consent</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:3 [ "identificador" => "xres816409" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec813645" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres816408" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec813646" "titulo" => "Palavras-chave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical disclosure" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 5 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-01-19" "fechaAceptado" => "2015-03-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec813645" "palabras" => array:4 [ 0 => "Anterolateral papillary muscle rupture" 1 => "Mitral regurgitation" 2 => "Right ventricular infarction" 3 => "Periprocedural myocardial infarction" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec813646" "palabras" => array:4 [ 0 => "Rotura do músculo papilar ântero-lateral" 1 => "Regurgitação mitral" 2 => "Enfarte do ventrículo direito" 3 => "Enfarte do miocárdio periprocedimento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rupture of the anterolateral papillary muscle following a right coronary artery occlusion is extremely rare, and when complicated by a right ventricular infarction, can be fatal. The literature on optimal management of this complication is limited. We present an unusual case of anterolateral papillary muscle rupture following intervention of the right coronary artery.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A rotura do músculo papilar ântero-lateral, na sequência da oclusão da artéria coronária direita é extremamente rara e, quando complicada por um enfarte do ventrículo direito, pode ser fatal. Presentemente, a literatura do tratamento otimizado da mesma é escassa. Apresentamos um caso muito particular da rotura do músculo papilar ântero-lateral, na sequência de uma intervenção à artéria coronária direita.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 822 "Ancho" => 1500 "Tamanyo" => 137706 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Angiography of the right coronary artery, with images before and after percutaneous coronary intervention (white arrow).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 730 "Ancho" => 1702 "Tamanyo" => 118554 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Subcostal transthoracic echocardiographic images showing anterolateral papillary muscle rupture and severe mitral regurgitation (white arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Papillary muscle rupture in fatal acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.Y. Wei" 1 => "G.M. Hutchins" 2 => "B.H. Bulkley" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "1979" "volumen" => "90" "paginaInicial" => "149" "paginaFinal" => "153" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/443647" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ischemic rupture of the anterolateral papillary muscle" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "V. Catarina" 1 => "G. António" 2 => "P.M. Álvares" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2012.06.014" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2013" "volumen" => "32" "paginaInicial" => "243" "paginaFinal" => "246" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23453536" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Isolated right coronary lesion and anterolateral papillary muscle rupture – case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Stefanovski" 1 => "A. Walfisch" 2 => "S. Kedev" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1749-8090-7-75" "Revista" => array:5 [ "tituloSerie" => "J Cardiothorac Surg" "fecha" => "2012" "volumen" => "7" "paginaInicial" => "75" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22898299" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanical complications of acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.S. Kutty" 1 => "N. Jones" 2 => "N. Moorjani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ccl.2013.07.004" "Revista" => array:7 [ "tituloSerie" => "Cardiol Clin" "fecha" => "2013" "volumen" => "31" "numero" => "4" "paginaInicial" => "519" "paginaFinal" => "531" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24188218" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Double papillary muscle infarction related to right coronary artery occlusion – a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.U. Güllü" 1 => "U. İnce" 2 => "E.M. Ökten" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5606/tgkdc.dergisi.2013.6337" "Revista" => array:2 [ "tituloSerie" => "Türk Göğüs Kalp Damar Cerrahisi Dergisi" "fecha" => "2013" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003400000011/v2_201703180236/S2174204915002664/v2_201703180236/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003400000011/v2_201703180236/S2174204915002664/v2_201703180236/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915002664?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 2 | 9 |
| 2024 October | 45 | 25 | 70 |
| 2024 September | 59 | 27 | 86 |
| 2024 August | 69 | 25 | 94 |
| 2024 July | 46 | 33 | 79 |
| 2024 June | 33 | 26 | 59 |
| 2024 May | 55 | 27 | 82 |
| 2024 April | 34 | 25 | 59 |
| 2024 March | 42 | 19 | 61 |
| 2024 February | 29 | 19 | 48 |
| 2024 January | 37 | 24 | 61 |
| 2023 December | 29 | 28 | 57 |
| 2023 November | 52 | 17 | 69 |
| 2023 October | 30 | 13 | 43 |
| 2023 September | 33 | 19 | 52 |
| 2023 August | 42 | 14 | 56 |
| 2023 July | 36 | 12 | 48 |
| 2023 June | 40 | 10 | 50 |
| 2023 May | 47 | 20 | 67 |
| 2023 April | 39 | 9 | 48 |
| 2023 March | 32 | 20 | 52 |
| 2023 February | 27 | 16 | 43 |
| 2023 January | 27 | 9 | 36 |
| 2022 December | 35 | 17 | 52 |
| 2022 November | 41 | 22 | 63 |
| 2022 October | 38 | 29 | 67 |
| 2022 September | 36 | 27 | 63 |
| 2022 August | 29 | 27 | 56 |
| 2022 July | 28 | 36 | 64 |
| 2022 June | 31 | 21 | 52 |
| 2022 May | 22 | 31 | 53 |
| 2022 April | 29 | 29 | 58 |
| 2022 March | 27 | 25 | 52 |
| 2022 February | 34 | 23 | 57 |
| 2022 January | 55 | 22 | 77 |
| 2021 December | 37 | 20 | 57 |
| 2021 November | 46 | 38 | 84 |
| 2021 October | 50 | 38 | 88 |
| 2021 September | 48 | 20 | 68 |
| 2021 August | 70 | 32 | 102 |
| 2021 July | 45 | 28 | 73 |
| 2021 June | 43 | 17 | 60 |
| 2021 May | 46 | 34 | 80 |
| 2021 April | 90 | 33 | 123 |
| 2021 March | 70 | 18 | 88 |
| 2021 February | 94 | 13 | 107 |
| 2021 January | 48 | 8 | 56 |
| 2020 December | 42 | 11 | 53 |
| 2020 November | 54 | 20 | 74 |
| 2020 October | 36 | 18 | 54 |
| 2020 September | 57 | 13 | 70 |
| 2020 August | 32 | 4 | 36 |
| 2020 July | 59 | 14 | 73 |
| 2020 June | 63 | 10 | 73 |
| 2020 May | 51 | 4 | 55 |
| 2020 April | 50 | 17 | 67 |
| 2020 March | 56 | 17 | 73 |
| 2020 February | 95 | 30 | 125 |
| 2020 January | 42 | 6 | 48 |
| 2019 December | 44 | 11 | 55 |
| 2019 November | 51 | 5 | 56 |
| 2019 October | 52 | 9 | 61 |
| 2019 September | 20 | 6 | 26 |
| 2019 August | 30 | 3 | 33 |
| 2019 July | 34 | 6 | 40 |
| 2019 June | 42 | 21 | 63 |
| 2019 May | 42 | 13 | 55 |
| 2019 April | 24 | 16 | 40 |
| 2019 March | 88 | 11 | 99 |
| 2019 February | 71 | 7 | 78 |
| 2019 January | 50 | 10 | 60 |
| 2018 December | 76 | 17 | 93 |
| 2018 November | 100 | 18 | 118 |
| 2018 October | 116 | 19 | 135 |
| 2018 September | 59 | 12 | 71 |
| 2018 August | 33 | 5 | 38 |
| 2018 July | 21 | 5 | 26 |
| 2018 June | 39 | 5 | 44 |
| 2018 May | 57 | 8 | 65 |
| 2018 April | 68 | 6 | 74 |
| 2018 March | 77 | 6 | 83 |
| 2018 February | 44 | 7 | 51 |
| 2018 January | 63 | 2 | 65 |
| 2017 December | 48 | 4 | 52 |
| 2017 November | 23 | 7 | 30 |
| 2017 October | 31 | 12 | 43 |
| 2017 September | 26 | 8 | 34 |
| 2017 August | 32 | 9 | 41 |
| 2017 July | 20 | 8 | 28 |
| 2017 June | 34 | 17 | 51 |
| 2017 May | 28 | 29 | 57 |
| 2017 April | 26 | 18 | 44 |
| 2017 March | 30 | 12 | 42 |
| 2017 February | 27 | 3 | 30 |
| 2017 January | 37 | 3 | 40 |
| 2016 December | 35 | 10 | 45 |
| 2016 November | 27 | 3 | 30 |
| 2016 October | 37 | 7 | 44 |
| 2016 September | 43 | 10 | 53 |
| 2016 August | 23 | 1 | 24 |
| 2016 July | 7 | 2 | 9 |
| 2016 June | 9 | 2 | 11 |
| 2016 May | 14 | 4 | 18 |
| 2016 April | 15 | 1 | 16 |
| 2016 March | 19 | 8 | 27 |
| 2016 February | 22 | 16 | 38 |
| 2016 January | 20 | 15 | 35 |
| 2015 December | 14 | 5 | 19 |
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