[HSF] Image of the week - Ischemic papillary muscle rupture

[Ani Anyanwu]

Dear Tohru
 
I remember the picture of your case. I hope the patient has continued to do well. I think I agree with you in principal that cardiogenic shock should not necessarily mandate a replacement (I suspect your patients did better overall from their shock because you fixed their valve).
 
Would your approach generally be to assess any ruptured PM for reparability or are there clinical instances where you would say it is not worth taking the 'chance' of repair? Is this an approach you recommend any of us should employ; and if not what are the caveats? I have never seen this operation and the only technical tips I have are those yourself, Dr Gammie and Dr Frater have shared on HSF - is it an operation a novice like I should be considering for if faced with a patient with this condition or is it one that should be reserved for highly skilled and experienced surgeons?
 
Thanks
 
Ani
 



> From: toruasai at belle.shiga-med.ac.jp> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Image of the week - Ischemic papillary muscle rupture> Date: Wed, 12 Sep 2007 00:12:13 +0900> CC: > > Roberto, Prasanna and Bob:> Thanks for inviting me to this thread! Yes, I am a surgeon who would have > repaired it. Prasanna kindly uploaded my picture early in this year. I > reproduced panorama pictures to enclose. Please look at these.> Points of my repair are relocation of fibrous origins of ruptured PM head to > "other intact PM heads". There are often intact PM on ipsilateral side ( > anterolateral or posteromedial ) even in the major basal rupture of PM lake > your case. I transposed two heads ( responsible for A1 and A2) to intact > heads for P1 and P2 using 4-0 Prolene transfixing sutures respectively. It > worked out pretty well. This specific pathology demonstrates normal leaflet, > normal chordae and normal (small) LA. Why you even think about Gore-Tex? > Probably not essential.> Lesson I learned was as follows;> 1. Severe MR with cardiogenic shock does not always mean “unrepairable > valve”!> 2. Large segment of prolapse does not always mean “unrepairable valve”!> 3. A key for successful repair is to watch not ruptured PM but "other intact > PM ".> Hope to show you my video at Geneva, if you are coming!> ---> Tohru Asai> > > Roberto, Tohru Asai sent a picture of a case similar to this some time> > back and he had successfully reimplanted it. He can give the details.> > > Let see what happens, just look at the photo and tell me if anyone would> > have repaired it. The posterior wall of the ventricle was infarcted, the> > ventricle very dilated,I think a goretex cordae would have been risky.
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