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Year : 2022  |  Volume : 32  |  Issue : 1  |  Page : 60-62

Anterolateral papillary muscle rupture revealing infective endocarditis

1 Department of Cardiology, Hedi Chaker University Hospital of Sfax, University of Medicine of Sfax, Sfax, Tunisia
2 Department of Cardiovascular Surgery, Habib Bourguiba University Hospital of Sfax, University of Medicine of Sfax, Sfax, Tunisia

Date of Submission31-Jul-2021
Date of Decision26-Jan-2022
Date of Acceptance12-Feb-2022
Date of Web Publication20-Apr-2022

Correspondence Address:
Salma Charfeddine
Department of Cardiology, Hedi Chaker University Hospital of Sfax, University of Medicine of Sfax, BP 54, Cite Elhabib 3052, Sfax
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcecho.jcecho_57_21

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The rupture of mitral papillary muscles is a very rare complication of infective endocarditis (IE). We report a case of anterolateral papillary muscle rupture resulting in severe mitral regurgitation due to IE in a young man without previous heart disease. The patient underwent urgent mitral valve replacement. The isolated rupture of the mitral papillary muscle complicating IE is rare. Urgent surgery should be performed is such cases.

Keywords: Infective endocarditis, mitral regurgitation, papillary muscle rupture, surgery

How to cite this article:
Charfeddine S, Triki S, Gueldiche M, Ellouze T, Bahloul A, Triki F, Abid L. Anterolateral papillary muscle rupture revealing infective endocarditis. J Cardiovasc Echography 2022;32:60-2

How to cite this URL:
Charfeddine S, Triki S, Gueldiche M, Ellouze T, Bahloul A, Triki F, Abid L. Anterolateral papillary muscle rupture revealing infective endocarditis. J Cardiovasc Echography [serial online] 2022 [cited 2023 Apr 1];32:60-2. Available from: https://www.jcecho.org/text.asp?2022/32/1/60/343537

  Introduction Top

Infective endocarditis (IE) is not a rare disease.[1] It is more frequent in the presence of valvular disease.[1] The IE lesions consist of vegetations and valvular destructions that are located essentially on the valves. The rupture of the mitral papillary muscle due to IE is a very rare complication.[2],[3] We report here a case of severe mitral regurgitation occurring on normal mitral valve with anterolateral papillary muscle rupture due to IE.

  Case Report Top

A diabetic 26-year-old man was admitted to our center for prolonged fever for 2 weeks associated with fatigue and general malaise, as well as loss of appetite. He had no history of rheumatic or congenital heart disease. At admission, the patient was febrile at 39°C and tachycardic. His lung sounds were clear, and no cardiac murmur was audible. There were no signs of heart failure.

The laboratory tests showed an inflammatory syndrome. An echocardiographic evaluation revealed a normal global systolic left ventricular function, no valvular disease but we noted a 15 mm × 11 mm mobile oscillating large mass with an echogenic content attached to the mitral anterolateral papillary muscle [Figure 1]. The diagnoses of a large septic vegetation or a papillary hydatid cyst were hypothesized.
Figure 1: (a) Transthoracic echocardiogram (TTE), four chamber-view. Arrow points to large mobile mass in the left ventricle (LV) attached to the mitral apparatus. (b) Modified TTE four chamber view. Arrow points to the mass attached the anterolateral papillary muscle. (c) TTE parasternal long axis (PSLA) view. Measurements of the mass (arrow). (d) TTE color Doppler mode. The absence of color on the mass. (e and f) Transesophageal echocardiogram (TTE) views. Arrow points to the same mass in the left ventricle attached to the mitral apparatus. Ao: Aorta, LA: left atrium

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Hence, after infectious investigations (hemocultures, hydatid serology, and mycobacterium tuberculosis research), empirical intravenous (IV) antibiotic therapy was initiated with ceftriaxone, teicoplanin, metronidazole, and rifampicin. However, there was no clinical amelioration and fever had persisted. A thoracoabdominal computed tomography revealed multiple hypodensities of the brain, the liver, and the spleen consistent with septic emboli. Few days after hospitalization, the patient's clinical condition worsened and pulmonary congestion appeared suddenly. The physical examination revealed a new pansystolic murmur consistent with mitral regurgitation. There was no electrocardiographic change suggesting an acute or subacute myocardial infarction.

Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) examinations were repeated. Echocardiographic studies showed a hyperdynamic left ventricle with no regional wall motion abnormality but we noticed severe mitral regurgitation with a prolapse of the anterior mitral valve due to the rupture of the mitral anterolateral papillary muscle, which explained the patient clinical status [Figure 2]. The diagnosis of IE complicated by severe mitral regurgitation was established. The patient underwent urgent prosthetic mitral valve replacement. On surgical inspection, complete rupture of the anterolateral papillary mitral muscle was found [Figure 3].
Figure 2: (a) Transthoracic echocardiogram (TTE), parasternal long axis (PSLA) view. Arrow points to image prolapsed to the left atrium (LA) during. (b) Modified PSLA view showed important mitral regurgitation due to the anterior mitral valve prolapse. (c-e) Transesophageal echocardiogram (TEE). Arrow points to mobile mass in the left ventricle (LV) with important mitral regurgitation. (f) Transgastric TEE view. Arrow points to anterolateral papillary muscle rupture. Ao: Aorta

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Figure 3: Arrow points to the rupture of the tip of the anterolateral papillary muscle on surgical inspection

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Pathology showed a nonspecific inflammation, ischemic necrosis, and focal abscesses which were consistent with IE. Given the histologic examination results, the diagnosis was a rupture of anterolateral papillary muscle secondary to mitral valve IE. After 6 weeks of IV antibiotic therapy, the patient was uneventfully discharged.

  Discussion Top

IE is a commonly encountered clinical problem, especially in patients with predisposing heart disease.[1] Most often, the mitral valve regurgitation in IE is due to the destruction of the valvular leaflets themselves. The isolated rupture of the anterolateral papillary muscle is much rarer and has only been described to the best of our knowledge in four previous cases.[3],[4],[5],[6] There are many possible causes of ruptures of papillary muscle in IE that include ischemic necrosis due to coronary embolism,[7] deposition of bacteria due to aortic regurgitation,[8] or direct invasion along with the subvalvular apparatus by virulent germ such as staphylococcus.[9] In our case, the cause of mitral regurgitation was due to direct germ invasion of the papillary muscle. The TEE, with the transgastric view, is essential to determine the mechanism of mitral regurgitation in such cases.[10] The ruptured anterolateral papillary muscle is well-defined as a separate mass attached to the chordae.[10] Although we were unable to show any bacteria on histological examination and culture of the papillary muscle, active inflammation was a strong criterion for the IE diagnosis. The absence of isolated germ may be explained by the use of empiric antibiotics at admission.

In conclusion, the diagnosis of IE should be made if a large mass on the anterolateral muscle is observed on echocardiography in the case of sepsis, even in the absence of valvular disease. The rupture of the papillary muscle in the setting of mitral regurgitation should be considered.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. 2015 ESC guidelines for the management of infective endocarditis: The task force for the management of infective endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36:3075-128.  Back to cited text no. 1
Gouda P, Weilovitch L, Kanani R, Har B. Case report and review of nonischemic spontaneous papillary muscle rupture reports between 2000 and 2015. Echocardiography 2017;34:786-90.  Back to cited text no. 2
Whitehead NJ, Li S, Lai K. Anterolateral papillary muscle rupture in Staphylococcus aureus endocarditis due to direct bacterial invasion of papillary muscle. Echocardiography 2017;34:1382-4.  Back to cited text no. 3
Maruo T, Komiya T, Shimamoto T, Kadota K, Mitsudo K. Spontaneous papillary muscle rupture with localized endocarditis. Eur Heart J Cardiovasc Imaging 2015;16:115.  Back to cited text no. 4
Nurkalem Z, Gorgulu S, Orhan AL, Demirci DE, Sargin M, Gumrukcu G. Papillary muscle rupture secondary to infective endocarditis. Echocardiography 2008;25:901-3.  Back to cited text no. 5
Najib MQ, Lee HR, DeValeria PA, Vinales KL, Surapaneni P, Chaliki HP. Anterolateral papillary muscle rupture: An unusual complication of septic coronary embolism. Eur J Echocardiogr 2011;12:E10.  Back to cited text no. 6
Sugimoto T, Shimanuki T, Minowa T, Uchino H, Nakamura C. A case report of infective endocarditis with total rupture of the posterior papillary muscle after aortic valve replacement. Kyobu Geka 1998;51:1120-2.  Back to cited text no. 7
Moorjani N, Saad R, Gallagher P, Livesey S. Endocarditis of the mitral valve posteromedial papillary muscle. J Card Surg 2014;29:213-5.  Back to cited text no. 8
Terai H, Okada Y, Hamaya H, Sugiki K, Ohno T. Successful surgical treatment in a case of complete rupture of the posterior papillary muscle of the mitral valve caused by infective endocarditis. Nihon Kyobu Geka Gakkai Zasshi 1994;42:1101-4.  Back to cited text no. 9
Kim MY, Park CH, Lee JA, Song JH, Park SH. Papillary muscle rupture after acute myocardial infarction. Korean J Intern Med 2002;17:274-7.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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