Incomplete mitral leaflet closure in patients with papillary muscle dysfunction

Clinical acceptance of an association between papillary muscle dysfunction and mitral regurgitation is widespread, despite the lack of objective support. To evaluate a possible association, we performed echocardiographic examinations on 22 patients with prior myocardial infarction and clinical evidence of papillary muscle dysfunction, 40 patients with prior myocardial infarction and no clinical evidence of papillary muscle dysfunction, and 20 normal subjects. There was a unique pattern of incomplete mitral leaflet closure in a high percentage (91%) of infarct patients with mitral regurgitation. In these patients, one or both leaflets were effectively arrested within the cavity of the left ventricle during ventricular systole. Dyskinetic wall motion in the region immediately surrounding one of the papillary muscles was present in 23 of 24 patients (96%) with demonstrated incomplete closure. This study provides the first objective evidence that de novo mitral regurgitation in patients with prior myocardial infarction is due to dyskinesis involving the left ventricular myocardium beneath one of the papillary muscles, producing increased tension on the mitral leaflets and preventing normal closure.