Ruptura papil rnog miši a usled akutnog infarkta miokarda pra ena kardiogenim šokom, edemom plu a i bubrežnom insuficijencijom
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- Brandon Bates
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1 3 235 K A Z U I S T I K A UDC: Ruptura papil rnog miši a usled akutnog infarkta miokarda pra ena kardiogenim šokom, edemom plu a i bubrežnom insuficijencijom Radoje Ili *, Zoran Trifunovi *, Svetislav Tišma*, An elka Risti - -An elkov, Mili Veljovi Vojnomedicinska akademija, *Klinika za grudnu i kardijalnu hirurgiju, Klinika za urgentnu internu medicinu, Klinika za anesteziologiju i intenzivnu terapiju, Beograd Cilj. Prikaz slu aja uspešno hirurški rešene rupture anterolateralnog papilarnog miši a usled akutnog infarkta miokarda, pra ene kardiogenim šokom, plu nim edemom i bubrežnom insuficijencijom. Prikaz bolesnika. Prikazan je bolesnik star 62 godine iz Beograda koji je primljen pa posle odbio nastavak le enja na VMA zbog bola u grudima, pada pritiska i novonastalog šuma na srcu. Tre eg dana od po etka bolesti primljen je ponovo u VMA kao hitan slu aj, zbog hemoptizija. Ispitivanjem je dokazana ruptura anterolateralnog papilarnog miši a mitralnog zaliska. Ura ena je urgentna operacija bez obzira na kardiogeni šok i po etnu bubrežnu insuficijenciju. Operisan je uz ekstrakorporalnu cirkulaciju. Implantiran je vešta ki mitralni zalistak i ura ena je revaskularizacija miokarda venskim graftom na prednjoj descendentnoj arteriji. Zbog bubrežne insuficijencije drugog postoperativnog dana sprovedena je hemodijaliza. Dvadesetosmog dana od operacije otpušten je iz VMA hemodinamski stabilan, sa urednom bubrežnom funkcijom i izbalansiranom antikoagulantnom terapijom. Slu aj je pou an, jer govori o neprepoznatoj rupturi papilarnog miši a koja je dovela do kardiogenog šoka, hemoptizija i bubrežne insuficijencije. Zaklju- ak. Ruptura papilarnog miši a je fatalna komplikacija akutnog infarkta miokarda. Rana dijagnoza i urgentna hirurška intervencija spasavaju život kod kompletne rupture papilarnog miši a. Hirurško le enje, bez obzira što nosi visok operativni rizik, je terapija izbora. K lj u n e r e i : zalistak, mitralni, insuficijencija; infarkt miokarda; papilarni miši i; ruptura; hemoptizija; hemodinamika; šok, kardiogeni; bubreg, insuficijencija; zalisci srca, vešta ki; hemodijaliza; le enje, ishod. Uvod Mitralna insuficijencija kao posledica ishemijske bolesti srca je relativno esta i nastaje kod oko 20% bolesnika sa ishemijskom sr anom boleš u. Na sre u, manje od jednog na dvadeset bolesnika sa mitralnom regurgitacijom nakon infarkta miokarda ima hemodinamski zna ajnu disfunkciju mitralnog zaliska. Le enje i prognoza ishemijske mitralne regurgitacije zavise od stepena anatomskog ošte enja i dužine trajanja bolesti. Mitralna insuficijencija nastaje zbog teške ishemije ili infarkta u zoni distribucije leve ili desne koronarne arterije, ine i na taj na in funkciju papilarnog miši a inkompetentnom. Pored toga, diskinezija segmenata zida leve sr ane komore može poremetiti sinhronizaciju kontrakcije komore sa poreme ajem funkcije anulusa mitralnog zaliska. Izobli enje anulusa mitralnog zaliska remeti koaptaciju listi a valvule i dovodi do regurgitacije krvi, naro ito kod povišenog enddijastolnog pritiska u levoj komori. Neki bolesnici mogu imati epizodu mitralne regurgitacije kao posledicu intermitentne ishemije. Zna ajan broj bolesnika pokazuje suštinsko poboljšanje nakon jedino ura ene revaskularizacije miokarda (1). Hirurško le enje ishemijske mitralne regurgitacije (rekonstrukcija ili zamena mitralne valvule) je obavezno za Ili R, et al. Vojnosanit Pregl 2005; 62(3):
2 236 3 one bolesnike kod kojih umerena i teška mitralna insuficijencija dovodi do sr ane dekompenzacije (1, 2). Hirurgija kod komplikacija ishemijske bolesti srca podrazumeva hirurško rešavanje akutno nastale mitralne insuficijencije, defekta me ukomorske pregrade i postinfarktne aneurizme leve komore srca (2, 3). Ishemijska mitralna regurgitacija, kao posledica koronarne bolesti, može nastati putem tri mehanizma: rupture papilarnog miši a (kompletna ili parcijalna), disfunkcije papilarnog miši a zbog ishemije ili postinfarktne fibroze i dilatacije anulusa mitralne valvule u sklopu progresivne slabosti leve komore (3, 4). Sa rutinskim hirurškim le enjem ishemijske bolesti srca zapo elo se godine kada je Favaloro uveo venski kalem (graft) za revaskularizaciju miokarda. Prva saopštenja o hirurškom le enju rupture papilarnog miši a kod akutnog infarkta miokarda iste godine izneo je Austen sa saradnicima. Deset godina kasnije Gerbode, Cooley, Kirklin i dr. objavili su svoje rezultate u hirurškom le enju rupture papilarnog miši a prouzrokovane akutnim infarktom miokarda (5, 6). Prikaz bolesnika Bolesnik star 62 godine iz Beograda primljen je u Kliniku za urgentnu internu medicinu Vojnomedicinske akademije (VMA) god. u prepodnevnim satima, zbog bola u grudima, pada krvnog pritiska i pojave šuma na srcu, pod sumnjom na akutni koronarni sindrom, radi daljeg tretmana. Ina e, ve deset godina ima visok krvni pritisak sa maksimalnim vrednostima do 240/130 mmhg. Redovno uzima lekove pet godina i održava pritisak oko 130/80 mmhg. Primljen je sa pritiskom od 105/75 mmhg. Na prijemu EKG nalaz: sinusni ritam, frekvencija oko 80/min, sprovodne smetnje po tipu prednjeg levog hemibloka, retke ventrikulske ekstrasistole, blaga depresija ST segmenta u D1, avl i lateralnim odvodima od V4 do V6 i negativan T talas u istim odvodima. Standardni laboratorijski nalazi i nivo kardiospecifi nih enzima u granicama normale. Nekoliko puta ponovljen EKG bez novih promena. Istog dana, u ve ernjim satima, u stabilnom hemodinamskom stanju, na li ni zahtev u pratnji porodice, napušta kliniku. Tri dana kasnije, zbog progrediranja tegoba u vidu jakog gušenja, otežanog disanja i iskašljavanja sveže crvene krvi, obavljen je kardiološki i pulmološki pregled u nadležnoj civilnoj ustanovi u Beogradu i radi razjašnjenja etiologije hemoptizija i postavljene sumnje na disekaciju aorte ponovo se prima u VMA. Na prijemu se žali na jako gušenje, ose a bol u grudima, iskašljava svežu crvenu krv (navodno je iskašljao oko 1 litar krvi), tahikardi an je, tahipnoi an, dispnoi an, cijanoti an i ima nabrekle vene na vratu. Zbog vitalne ugroženosti preduzete su hitne dijagnosti ke mere. EKG nalaz bez novih promena u smislu evolucije ishemijske bolesti u odnosu na nalaz od pre tri dana. Laboratorijski nalazi: leukociti 15,5 109/l, kreatinin 216 mmol/l, BUN 24,6 mmol/l, osmolarnost 314, enzimi: SGOT 73, SGPT 65, LDH 707, HBDH 252 i CPK-MB 32 jedinice. Radiografijom srca i plu a uo avaju se teške zastojne promene u plu ima i blago uve ana sr ana senka (slika 1). Sl. 1 Radiografija plu a i srca ukazuje na zastojne promene u plu ima. Zbog hemoptizija i bola u grudima (da bi se isklju ila eventualna disekacija grudne aorte) ura en je CT pregled grudnog koša. Ura enim pregledom je isklju ena disekacija grudne aorte, ali se u plu nom parenhimu obostrano, više desno, registruje od vrhova prema kaudalno mrljasta konsolidacija plu nog parenhima sa pleuralnim izlivima obostrano (slika 2). Sl. 2 CT snimak grudnog koša sa slikom obostrane konsolidacije plu nog parenhima. U injenim pregledima nije razjašnjena priroda hemoptizija, a s obzirom na podatak o novonastalom šumu na srcu, bolesniku je ura en ehokardiografski pregled srca. Transtoraksnom ehokardiografijom (TTE) je vi en izrazit prolaps prednjeg kuspisa mitralnog zaliska sa hemodinamski zna ajnom mitralnom regurgitacijom stepena 3+ i opisuje se masivna vegetacija na prednjem kuspisu koja u sistoli leve komore prolabira u levu pretkomoru. Kontraktilnost miokarda leve komore je o uvana, istisna funkcija leve komore je procenjena na oko 70%. Leva komora je u fiziološkim granicama, bez segmentnih ispada kontraktilnosti, leva pretkomora je normalne veli ine (slika 3).
3 3 237 Bolesnik je, i pored inotropne stimulacije i intenzivne terapije diureticima, ispoljavao znake kardiogenog šoka, hemoptizije su se i dalje održavale, a pojavili su se i znaci bubrežne insuficijencije. I pored ovako teškog klini kog stanja, doneta je odluka da se uradi koronarografija. Selektivnom koronarografijom leve koronarne arterije dokazana je suptotalna stenoza prednje descendentne grane (LAD) leve koronarne arterije, posle ishodišta prve septalne i prve dijagonalne arterije (slika 4). Koronarografski nalaz na desnoj koronarnoj arteriji je bez patoloških promena (slika 5). Zaklju ak je kona no bio jasan radi se o rupturi prednjeg papilarnog miši a mitralnog zaliska kao posledica suptotalne stenoze prednje descendentne koronarne arterije u fazi akutnog infarkta miokarda i sledstveno nastale hemodinamski teške mitralne insuficijencije pra ene edemom plu a, kardiogenim šokom i po etnom bubrežnom insuficijencijom. Indikuje se hitna hirurška intervencija koja je ura- ena uz ekstrakorporalnu cirkulaciju. Ura ena je revaskularizacija miokarda venskim graftom na LAD. Otvorena je leva pretkomora. Mitralni zalistak je na en sa kompletnom rupturom prednjeg papilarnog miši a tako da odvaljena miši na masa prominira u levu pretkomoru. Ekscidovan je mitralni zalistak, a zatim je u mitralno uš e implantirana vešta ka dvolisna valvula Carbomedics M-31 (slika 6). Odvajanje od kardiopulmonalnog premoš avanja je obavljeno uz pomo inotropne podrške. Bolesnik je sa blagom inotropnom stimulacijom premešten u jedinicu za hiruršku intenzivnu terapiju. a) b) Sl. 4 Koronarografski prikaz leve koronarne arterije gde se uo ava suptotalna stenoza prednje descendentne arterije. Sl. 3 Transezofagusni snimak rupture papilarnog miši a mitralnog zaliska u raznim fazama sr ane revolucije. Strelica pokazuje rupturisani deo papilarnog miši a. c) Sl. 5 Koronarografski prikaz desne koronarne arterije. Sl. 6 Ekscidovan mitralni zalistak sa rupturisanim delom anterolateralnog papilarnog miši a nazna en strelicom
4 238 3 Za vreme operacije bolesnik je izmokrio 200 ml. U ve- ernjim satima bolesnik se probudio i nastavio se postoperativni oporavak na mehani koj ventilaciji. Diureza za prvi postoperativni dan iznosila je ml. U daljem postoperativnom toku, i pored intenzivne diuretske terapije, ispoljavaju se znaci bubrežne insuficijencije sa porastom azotnih materija i kalijuma u serumu, tako da je kreatinin bio 425 mmol/l, BUN 31,6 mmol/l, K 5,5 mmol/l, te je uz konsultaciju sa nefrologom, doneta odluka da se drugog postoperativnog dana u ve ernjim satima uradi hemodijaliza. Nakon hemodijalize uspostavljena je diureza tako da je narednih dana bolesnik dnevno mokrio izme u ml i ml. Sa uspostavljanjem diuretske funkcije svakodnevne radiografske kontrole plu a, pokazuju progresivnu regresiju zastojnih promena u plu ima. etrnaestog postoperativnog dana, u stabilnom hemodinamskom stanju, sa normalnim biohumoralnim nalazima, bolesnik je premešten u odeljenje. Otpušten je iz VMA hemodinamski stabilan, sa urednim ehokardiografskim nalazom na srcu, urednom radiografijom srca i plu a, normalnim pokazateljima bubrežne funkcije i izbalansiranom antikoagulantnom terapijom (slika 7). Sl. 7 Radiografija plu a i srca nakon završenog le enja. Histološki nalaz na ekscidovanoj mitralnoj valvuli: fibrosis, degeneratio mucoides et calcificatio valvulae cordis (analizovan je deo mitralne valvule sa tetivnim hordama i papilarnim miši ima, zalisci su beli asti i lako zadebljali, a papilarni miši i hipertrofi ni). Diskusija Analizuju i klini ki tok bolesti, dijagnosti ke dileme u pojedinim fazama ispitivanja, izuzetno teško stanje bolesnika sa ošte enjem funkcije nekoliko vitalnih organa i uspešan ishod le enja, može se rekonstruisati i objasniti patofiziološki tok bolesti kod prikazanog bolesnika. Bolesnik je etiri dana pre operativnog zahvata, prema dinamici porasta kardiospecifi nih enzima, na nogama preležao akutni infarkt miokarda prednjeg zida. Novonastali šum na srcu, nekarakteristi an EKG nalaz za infarkt miokarda i pojava hemoptizija tre eg dana od po etka bolesti su uneli nove dileme u dijagnosti kom razjašnjenju prirode bolesti. U ovoj fazi dijagnostike dodatno se unosi sumnja na disekaciju aorte koja je otklonjena nakon ura enog CT pregleda grudnog koša. Znaci disekacije aorte nisu vi eni CT pregledom, ali u nalazu dominira konsolidacija plu nog parenhima. Ehokardiografski pregled srca je usmerio dijagnostiku na pravi put. Ultrasonografskim pregledom srca (TTE i TEE) je dokazana hemodinamski zna ajna mitralna regurgitacija zbog prolapsa prednjeg kuspisa mitralnog zaliska na kome je na ena velika verukozna masa koja mlati i u sistoli prolabira u levu pretkomoru. Sa velikom verovatno om je postavljena sumnja na ishemijsku genezu rupture prednjeg papilarnog miši a. Doneta je odluka da se, bez obzira na kardiogeni šok teško stanje u kom se bolesnik nalazio, uradi selektivna koronarografija, što se u ovom slu aju pokazalo potpuno ispravnom odlukom. Koronarografijom je dokazana suptotalna stenoza prednje descendentne arterije i ovim nalazom je definitivno razjašnjen patofiziološki tok bolesti. Zbog kombinovanih valvularno-koronarnih problema ura ena je implantacija vešta kog zaliska u mitralno uš e i revaskularizacija miokarda venskim aortokoronarnim graftom na LAD. Kardiogeni šok iz preoperativnog perioda uveo je bolesnika u bubrežnu insuficijenciju koja je drugog postoperativnog dana bila na tom stepenu da je morala da se sprovede hemodijaliza. Nakon toga se, oporavak bolesnika, uz standardnu medikamentnu podršku, odvijao uzlaznom linijom, tako da je posle dvadeset osam dana od operacije, potpuno oporavljen, u odli nom hemodinamskom stanju otpušten iz klinike. Kompletna ruptura papilarnog miši a je smrtonosna kod 70% bolesnika u prvih 24 sata i kod skoro 90% u toku 2 nedelje od rupture, zato što zahva eni listi prolabira i daje masivnu akutnu mitralnu regurgitaciju (2). Klini ki nalaz kod ovih bolesnika obavezno uklju uje novonastali sistolni šum na srcu koji se širi u aksilu i koji je udružen sa masivnim edemom plu a i kardiogenim šokom zbog malog minutnog volumena. Naj eš e se ovo teško klini ko stanje razvija izme u drugog i sedmog dnana od akutnog infarkta miokarda. Poznavaoci ove problematike upozoravaju da kao mogu e uzroke rupture papilarnog miši a treba uzeti u obzir tupu traumu grudnog koša, infektivni endokarditis, mezenhimopatije (sistemski eritemski lupus) i invazivne kardiološke procedure naj eš e endomiokardnu biopsiju (7 12). Od zna aja je da, prema podacima iz literature, oko 70 80% bolesnika sa akutnom rupturom papilarnog miši a ima infarkt posteromedijalnog miši a udružen sa infarktom donjeg zida, a samo 20% ima leziju anterolateralnog papilarnog miši a zajedno sa anterolateralnim infarktom. Niža incidencija rupture anterolateralnog papilarnog miši a uslovljena je patoanatomskim razlozima. Naime, prednji papilarni miši je vaskularizovan prednjom descendentnom arterijom, dijagonalnom granom i granama arterije cirkumflekse. S druge strane, posteromedijalni papilarni miši je vaskularizovan jedino zadnjom descendentnom granom desne koronarne arterije (2, 3). Ošte enje miši ne mase miokarda zahva enog infarktom i akutno nastala mitralna insuficijencija su razlozi za nastanak kardiogenog šoka. Mali udarni volumen (low car-
5 3 239 diac output) sa svoje strane dovodi do ošte enja funkcije drugih organa, u našem slu aju do bubrežne insuficijencije i edema plu a. Jedna od najdramati nijih komplikacija ishemijske sr- ane bolesti koja dovodi do mitralne regurgitacije je ruptura papilarnog miši a. Ona nastaje kod 1 2% bolesnika nakon infarkta miokarda, obi no izme u prvog i desetog dana nakon infarkta. Kod bolesnika se naj eš e razvija edem plu a koji progredira u kardiogeni šok. Veli ina infarkta, prema podacima iz literature, a što je i nalaz u našem slu aju, nije u direktnoj srazmeri sa nastankom rupture papilarnog miši- a. Nasuprot tome, pokazalo se da infarkti koji zahvataju malu miši nu masu miokarda leve komore daju kao komplikaciju rupturu papilarnog miši a (13). Diskrepancija izme u malih EKG promena i blagih pove anja nivoa enzima u serumu sa pojavom edema plu a dovode do dijagnosti kih dilema, tako da je dijagnostika u jednom trenutku skrenuta u smeru razjašnjenja etiologije edema plu a. Ehokardiografija je dovoljna i suverena metoda za postavljanje dijagnoze rupture papilarnog miši a. Ultrasonografski pregled srca (TTE i TEE) daje dragocene preoperativne anatomske detalje o stanju istisne funkcije leve komore, veli ini leve pretkomore i druge podatke koji su od neprocenjivog zna aja za predstoje i hirurški zahvat. Rupturu papilarnog miši a treba izdiferentovati od postinfarktne rupture interventrikularnog septuma. Odsustvo levo desnog šanta na nivou komora je sigurna ehokardiografska potvrda da nije došlo do razvoja postinfarktnog defekta me- ukomorske pregrade (14 17). Koronarna angiografija odlaže hiruršku intervenciju za izvesno vreme, ali sigurno identifikuje krvne sudove za revaskularizaciju. Bez obzira na izuzetno teško stanje poreme ene hemodinamike ura ena je koronarografija koja je pokazala suptotalnu stenozu prednje descendentne arterije. Pozitivan koronarografski nalaz upu uje hirurga na arteriju koju treba revaskularizovati, a s druge strane, u najnovije vreme, postoje mišljenja da prvo treba uraditi primarnu koronarnu angioplastiku da bi se postigla hemodinamska stabilnost bolesnika, a zatim pristupiti hirurškoj intervenciji. Neki autori, pored medikamentne terapije (inotorpni lekovi, diuretici, vazodilatatori i ACE inhibitori za smanjenje optere enja volumenom (afterload)) predlažu primenu tromboliti ke terapije i inserciju intraaortne balon pumpe da efektom kontrapulsacije smanje periferni otpor, poboljšaju koronarni protok i da bi se nakon stabilizacije hemodinamike pristupilo operativnom le enju (18, 19). Urgentna hirurška intervencija je indikovana im se postavi dijagnoza rupture papilarnog miši a. Zamena za hiruršku intervenciju, uprkos visokom operativnom mortalitetu od 50%, ne postoji. Najbolja terapijska opcija kod rupture prednjeg papilarnog miši a je implantacija vešta ke mitralne valvule (po mogu stvu sa o uvanjem zadnjeg kuspisa) i aortokoronarno premoš avanje na infarciranoj arteriji (20 22). Ne preporu uje se rekonstrukcija zaliska i implantacija prstenova za korekciju zaliska jer je rupturisani miši u fazi zapaljenja i sa histološkom slikom nekroze tako da su rekonstruktivni zahvati nesigurni. Preporu uje se implantacija vešta kih niskoprofilnih valvula u mitralno uš e. Zbog akutno nastalog stanja leva pretkomora nije uve ana tako da hirurg nema dovoljno prostora da bi u komforu i sa pravim uvidom u strukture uradio neki rekonstruktivni zahvat (5, 6, 15, 23, 24). Ruptura papilarnog miši a narušava hemodinamiku do najtežeg stepena i dovodi do multiorganskih ošte enja. U našem slu aju klini ko stanje se komplikovalo i bubrežnom insuficijencijom zbog ega je drugog postoperativnog dana morala da se sprovede hemodijaliza. Zaklju ak Ruptura papilarnog miši a je, naj eš e, fatalna komplikacija akutnog infarkta miokarda. Naš slu aj je veoma ilustrativan jer je uspešno hirurški rešena teška komplikacija akutnog infarkta miokarda udružena sa sekundarnim ošte enjem drugih organa. Rana dijagnoza i urgentna hirurška intervencija spasavaju život kod kompletne rupture papilarnog miši a. Hirurško le enje je terapija izbora, bez obzira što nosi visok operativni rizik. S obzirom na multiorganska ošte enja koja prate ovo teško klini ko stanje, uspešno hirurško rešavanje se može obaviti isklju ivo u ustanovama koje imaju mogu nosti da se u svakom trenutku pristupi svim neophodnim dijagnosti kim i terapijskim procedurama. LITERATURA 1. Waldhausen JA, Orringer MB. Complications in Cardiothoracic Surgery. London: Mosby Year Book; Messika-Zeitoun D, Fung Yiu S, Grigioni F, Enriquez- Sarano M. Role of echocardiography in the detection and prognosis of ischemic mitral regurgitation. Rev Esp Cardiol 2003; 56(6): (Spanish) 3. Yoshida S, Sakuma K, Ueda O. Acute mitral regurgitation due to total rupture in the anterior papillary muscle after acute myocardial infarction successfully treated by emergency surgery. Jpn J Thorac Cardiovasc Surg 2003; 51(5): Jones EL, Hatcher C Jr. Techniques for the Surgical Treatment of Atherosclerotic Corronary Artery Disease and its complications. In: Hurst W, editor. The Heart. 6th ed. New York: McGraw-Hill; p Austen WG, Sokol DM, DeSanctis RW, Sanders CA. Surgical treatment of papillary-muscle rupture complicating myocardial infarction. N Engl J Med 1968; 278(21): Gerbode FL, Hetzer R, Krebber HJ. Surgical management of papillary muscle rupture due to myocardial infarction. World J Surg 1978; 2(6):
6 Bailey PL, Peragallo R, Karwande SV, Lapunzina P. Mitral and tricuspid valve rupture after moderate blunt chest trauma. Ann Thorac Surg 2000; 69(2): Simmers TA, Meijburg HW, de la Riviere AB. Traumatic papillary muscle rupture. Ann Thorac Surg 2001; 72(1): Bruschi G, Agati S, Iorio F, Vitali E. Papillary muscle rupture and pericardial injuries after blunt chest trauma. Eur J Cardiothorac Surg 2001; 20(1): Kalra PR, Ohri SK, Morgan JM. Images in cardiology. Mitral regurgitation secondary to ruptured papillary muscle. Heart 2000; 84(1): Lemke P, Roth M, Kraus B, Hohe S, Klovekorn WP, Bauer EP. Ruptured papillary muscle after mitral valve replacement with preservation of chordae tendineae. Ann Thorac Surg 2001; 72(4): Tokuda Y, Matsumoto M, Sugita T, Nishizawa J, Matsuyama K, Yoshida K, et al. Mitral valve repair for severe mitral regurgitation caused by endomyocardial biopsy. J Heart Valve Dis 2002; 11(6): Takahashi T, Kohno K, Kashida M, Morita T, Saito K, Kamei A, et al. A survival case of acute mitral regurgitation and cardiogenic shock caused by subtotal occlusion of the first diagonal branch. Circ J 2002; 66(6): Srichai MB, Casserly IP, Lever HM. Cardiac tamponade masking clinical presentation and hemodynamic effects of papillary muscle rupture after acute myocardial infarction. J Am Soc Echocardiogr 2002; 15(9): Apetrei E, Rugina M, Iliescu V, Deleanu D, Miclea I, Filipescu D, et al. Anterolateral papillary muscle rupture: diagnosis and successful treatment (a case report). Echocardiography 2002; 19(2): Rerkpattanapipat P, Bajpai E, Maraj R, Pym J, Jacobs LE, Kotler MN. Complete rupture of the papillary muscle. Echocardiography 2000; 17(6 Pt 1): Iwasaki K, Matsuo N, Hina K, Murakami T, Murakami M, Matano S, et al. Transesophageal echocardiography for detection of mitral regurgitation due to papillary muscle rupture or dysfunction associated with acute myocardial infarction: a report of five cases. Can J Cardiol 2000; 16(10): Oxorn D, Curtis W, Burnett R. Ruptured papillary muscle. Eur J Cardiothorac Surg 2000; 18(5): Wada H, Yasu T, Murata S, Ohta M, Kubo N, Fujii M, et al. Rupture of the anterolateral papillary muscle caused by a single diagonal branch obstruction. Circ J 2002; 66(9): Chen Q, Darlymple-Hay MJ, Alexiou C, Ohri SK, Haw MP, Livesey SA, et al. Mitral valve surgery for acute papillary muscle rupture following myocardial infarction. J Heart Valve Dis 2002; 11(1): Tavakoli R, Weber A, Vogt P, Brunner HP, Pretre R, Turina M. Surgical management of acute mitral valve regurgitation due to post-infarction papillary muscle rupture. J Heart Valve Dis 2002; 11(1): Moustapha A, Lyngholm K, Barasch E. Isolated acute anterolateral papillary muscle rupture presenting as a sole manifestation of acute myocardial infarction and mimicking mitral valve vegetation. Cardiology 2001; 96(1): Assi ER, Tak T. Posterior myocardial infarction complicated by rupture of the posteromedial papillary muscle. J Heart Valve Dis 1999; 8(5): Shah A, Kronzon I. The enigma of occult mitral regurgitation in a patient with cardiogenic shock. J Am Soc Echocardiogr 2003; 16(10): Rad je primljen 25. VIII god. Abstract Ili R, Trifunovi Z, Tišma S, Risti -An elkov A, Veljovi M. Vojnosanit Pregl 2005; 62(3): PAPILLARY MUSCLE RUPTURE DUE TO ACUTE MYOCARDIAL INFARCTION FOLLOWED BY CARDIOGENIC SHOCK, PULMONARY EDEMA, AND ACUTE RENAL FAILURE Aim. The case of successfull surgical treatment of anterolateral papillary muscle rupture due to acute myocardial infarction with cardiogenic shock, pulmonary edema and acute renal failure. Case report. A 62-year old male from Belgrade with chest pain, hypotension and a new heart murmur refused hospitalization at the Military Medical Academy. On the third day of his illness he was readmitted to MMA as an emergency due to hemoptysis. Examination revealed mitral valve anterolateral papillary muscle rupture. The patient, with signs of cardiogenic shock and acute renal failure, was immediately operated on. The surgery was performed using extracorporeal circulation. An artificial mitral valve was implanted, and myocardial revascularization accomplished with one venous graft of the left anterior descend-
7 3 241 ing artery. On the second postoperative day, hemodialysis was carried out due to acute renal failure. On the 28 th postoperative day, the patient was discharged from the hospital being hemodynamically stable with normal renal function and balanced anticoagulation. The case is interesting in terms of unrecognized papillary muscle rupture that led to the development of cardiogenic shock, hemoptysis and acute renal failure. Conclusion. Papillary muscle rupture is a fatal complication of acute myocardial infarction. Early recognition and urgent surgical intervention were lifesaving in the case of complete papillary muscle rupture. Surgical treatment, regardless of high risk, is the procedure of choice. K e y w o r d s : mitral valve insufficiency; myocardial infarction; papillary muscles; rupture; hemoptysis; hemodynamic phenomena; shock, cardiogenic; kidney failure; heart valve prosthesis; renal dialysis; treatment outcome. Correspodence to: Radoje Ili, Vojnomedicinska akademija, Klinika za grudnu i kardijalnu hirurgiju; Crnotravska 17, Beograd, Srbija i Crna Gora. Tel
Ivica Djuri *, Slobodan Obradovi *, Branko Gligi *
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