Acute Mitral Regurgitation Secondary to Papillary Muscle Tear
Is Transcatheter Edge-to-Edge Mitral Valve Repair a New Paradigm?
- mitral regurgitation
- myocardial infarction
- papillary muscle
- percutaneous mitral valve repair
Severe mitral regurgitation (MR) secondary to papillary muscle tear is an infrequent but overwhelmingly morbid and often fatal complication of acute myocardial infarction occurring in 1% to 3% of patients.1 In-hospital mortality without surgical correction can approach 80%2; however, even with surgical correction, papillary muscle tear carries a mortality rate between 19% and 53%.2–5 While consideration of emergent surgical correction continues to be indicated6 with undeniable impact on mortality, outcomes have remained poor over time, with a mortality of nearly 40% in a contemporary evaluation of clinical outcomes.5 Additionally, over 50% of patients with severe MR complicating acute myocardial infarction are declined for surgical intervention because of ongoing instability, shock, or the presence of comorbidities that make surgery of prohibitive risk.2 Thus, although mitral valve repair is necessary for these patients, surgical correction remains an imperfect and incomplete solution.
The emergence of percutaneous interventions for valvular heart disease have offered opportunities for many patients that previously were without therapeutic options.7–9 Specifically, in patients with severe chronic MR with elevated surgical risk, the development and advancement of the MitraClip has offered an alternative to high or prohibitive-risk surgical intervention. With MitraClip as a viable alternative to mitral valve replacement or repair for high-risk patients with chronic MR, is it time to consider its possible use in the setting of those high-risk patients with acute MR secondary to myocardial infarction? If so, an optimal approach for decision-making and management of these patients needs to be developed, incorporating procedural aspects and considerations of percutaneous versus surgical repair.
We describe a clinical case of a patient with severe MR after acute myocardial infarction and discuss the management for such patients in the current era of percutaneous intervention for valvular heart disease.