Surgical management of papillary muscle rupture due to myocardial infarction

Complete or partial rupture of a papillary muscle following myocardial infarction is a severe complication that, without surgical intervention, results in a mortality rate of 95%. Of 41 patients with papillary muscle rupture who were treated surgically, the overall operative mortality rate was 48%, with an 87% mortality rate in 13 patients who entered the hospital in critical condition within 1 month after myocardial infarction. There was an operative mortality rate of 50% in the second month and 33% in the third month following myocardial infarction. Of the patients who underwent operation more than 4 months after infarction, 73% survived. Of 51 patients operated upon for ruptured chordae tendineae of the posterior leaflet of the mitral valve, there were only 2 early and 3 cardiac‐related late deaths. Of these 51 patients, 43 are currently virtually asymptomatic. Methods to improve the results of surgical therapy in the critically ill patient include drug support for afterload reduction and increased contractility and/or mechanically induced afterload reduction, and diastolic augmentation by intra‐aortic balloon counterpulsation. Because the uninterrupted course of papillary muscle rupture is lethal in almost all cases, attempts should be made to improve the patient's condition in order to allow surgical intervention under optimal conditions. The surgical treatment for ruptured papillary muscle is usually mitral valve replacement. For ruptured chordae of the posterior leaflet, the preferred treatment is plastic repair. Résumé La rupture complète ou partielle d'un muscle papillaire après infarctus du myocarde est une complication grave. Non opérée, elle donne 95% de décès. Nous avons opéré 41 malades atteints de rupture d'un muscle papillaire. La mortalité globale a été de 48%. Elle a été de 87% pour 13 malades admis à l'hôpital dans un état grave au cours du premier mois post‐infarctus, de 50% pour les malades opérés pendant le deuxième mois et de 33% pour les opérés au troisième mois. Parmi les patients opérés plus de quatre mois après infarctus, 73% ont survécu. Sur 51 malades opérés pour rupture de cordage tendineux de la valve mitrale postérieure, il y a eu 2 décès précoces et 3 décès cardiaques tardifs; 43 malades sont pratiquement sans symptome. Pour améliorer les résultats de la chirurgie chez ces malades graves, on peut utiliser des drogues diminuant l'afterload, augmentant la contractilité et/ ou réduisant l'afterload d'origine mécanique, ou empl