Papillary muscle rupture

Last revised by Joachim Feger on 17 Dec 2021

Papillary muscle rupture (PMR) is a dangerous complication that can evolve as a consequence of myocardial infarction or infective endocarditis leading to severe acute mitral or tricuspid regurgitation leading to left or right-sided heart failure.

Papillary muscle rupture is rare and frequency is estimated in 0.5-5% of myocardial infarctions. It is more common in first-time coronary events and can be also seen in smaller infarctions 1-4.

Papillary muscle rupture is associated with the following conditions:

Signs and symptoms are subject to the affected valve. As for left ventricular papillary muscle rupture patients usually present with symptoms of acute heart failure including severe dyspnea, orthopnea and hypoxia in the immediate post-myocardial infarction period up to one week 1. Chest pain and hypotension and other signs of cardiogenic shock are further symptoms 1-4.

Complications of papillary muscle rupture 1-4:

Rupture of a papillary muscle can be complete affecting the trunk that supports half of the chordae tendineae to both mitral valve leaflets or partial, affecting one or more of several muscle heads 1.  

Causes of papillary muscle rupture include the following 1-5:

Five papillary muscles in the heart can potentially be affected: the anterolateral and posteromedial papillary muscles in the left ventricle 1-5, which attach to the mitral valve and three papillary muscles attaching to the tricuspid valve.

The posteromedial papillary muscle complex of the left ventricle seems to be the most frequently affected 1-4, typically in the setting of precedent myocardial infarction with the involvement of the posterior descending artery 1.

Transthoracic or transesophageal echocardiography is considered is usually a first-line imaging modality for the evaluation of mitral valvular disorders. Findings include the following 2:

  • mitral or tricuspid regurgitation
  • flail leaflet or bi-leaflet prolapse
  • ruptured papillary muscle head with detachment
  • mobile masses attached to the chordae tendineae

Patients with a complete papillary muscle rupture will probably rarely undergo cardiac MRI due to hemodynamic instability. However, MRI can demonstrate the rupture with myocardial edema and signs of myocardial infarction or myocardial injury of the papillary muscle and the adjacent myocardium including the following 1:

The radiological report should include a description of the following features 1:

Prognosis of left ventricular papillary muscle rupture without surgical treatment is poor with a high mortality rate especially in the case of complete rupture. Initial medical therapy includes oxygen therapy, vasodilator therapy, diuretics and afterload reduction. Intra-aortic balloon counterpulsation might be also helpful.

Surgical management consists of mitral valve repair or mitral valve replacement with coronary artery bypass grafting 1-6.

Papillary muscle rupture was first described by Merat in 1803 in a post mortem examination and by S. Davison in 1948 on antemortem 2,7.

Conditions mimicking the imaging the clinical presentation and imaging appearance of papillary muscle rupture include:

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