Papillary Muscle Rupture After Blunt
Chest Trauma
Adriana Cordovil, MD, Claudio H. Fischer, MD, Ana Clara T. Rodrigues, MD,
Edgar B. Lira Filho, MD, Marcelo L. C. Vieira, MD, Alexandre F. Cury, MD,
Gustavo A.F. Naccarato, MD, Carmen Valente, MD, Carlos M. Brandão, MD,
Pablo M. Pommerantzeff, MD, and Samira S. Morhy, MD, São Paulo, Brazil
We report a case of anterolateral papillary muscle
rupture in a 22-year-old man who had blunt chest
trauma caused by a car accident. Transesophageal
echocardiography revealed severe mitral regurgi-
CASE REPORT
A 22-year-old man was involved in a car crash and was
initially taken to another hospital, where he arrived con-
scious, with no evidence of external chest wounds. The
same night, he developed acute respiratory insufficiency
and was placed under ventilatory support. As ventilatory
parameters became progressively worst, the patient was
referred to our institution 4 days after the accident. On
admission in our hospital he presented on physical exam-
ination evidences of pulmonary edema with associated
hypotension (blood pressure 70/30 mm Hg), despite
inotropic drug support, pulse 143/min, and pulse oxime-
ter showed 50% oxygen saturation. Cardiac auscultation
revealed systolic murmur 2/6 best heard at the cardiac
apex. Except for sinus tachycardia, the electrocardiogram
findings were normal. Computed tomographic scan of the
head showed facial bone fractures, whereas chest com-
puted tomographic scan revealed bilateral pulmonary
edema and normal aorta.
Emergency transesophageal echocardiogram (TEE) was
performed because of a limited transthoracic acoustic
window. Echocardiographic findings were consistent
with a partial ruptured papillary muscle head resulting
in severe mitral regurgitation on color flow mapping
(Figure and Video). Except for minimal left atrial dilation,
cardiac chambers were normal. Although left ventricle
was hyperdynamic, right ventricle function was mildly
decreased. There was no pericardial effusion, and the
evaluation of the aorta showed no injury.
From the Echocardiography Laboratory, Hospital Israelita Albert
Einstein.
Reprint requests: Adriana Cordovil, MD, Av Pe Pereira de
Andrade 545/193D, 05469000 São Paulo, Brazil (E-mail:
acordovil@cardiol.br).
0894-7317/$32.00
Copyright 2006 by the American Society of Echocardiography.
doi:10.1016/j.echo.2005.12.005
tation caused by the rupture. He successfully under-
went emergency mitral valve replacement and was
discharged 9 days after the surgical correction. (J Am
Soc Echocardiogr 2006;19:469.e1-469.e3.)
As soon as the diagnosis was established, surgical
intervention was attempted. In the first hospital, creatine
phosphokinase dosage was not done as well as in ours,
because the patient was submitted to surgical correction
immediately after echocardiographic diagnosis. Operative
findings were consistent with echocardiographic diagno-
sis. Complete rupture of the anterolateral papillary muscle
was found, with laceration occurring at midmuscle level
and complete transection at the basal ventricular wall.
Mitral valve chordae tendineae were not affected. Accord-
ing to anatomic damage it was not possible to use
conservative surgical techniques, such as Duran and Car-
pentier rings. Thus, the whole mitral valve apparatus was
excised and the valve was replaced by a bioprosthesis.
A second TEE examination was performed on the first
postoperative day and showed normally functioning mi-
tral bioprosthesis. The patient had an uneventful recovery,
and was discharged on the ninth postoperative day.
DISCUSSION
Blunt trauma is more frequently associated with
cardiac contusion, cardiac rupture, and aortic injury,
and may be uncommonly be followed by intracar-
diac valvular or papillary muscle injuries.1 The rarity
of mitral valve trauma was demonstrated by Parmley
et al2 in an autopsy series. However, with the
increasing number of traffic accidents, the preva-
lence and severity of these lesions are probably
underestimated.3 Besides, this kind of injury re-
quires a high degree of diagnostic suspicion.
Valvular injury occurs more frequently to the
aortic valve, followed by mitral and tricuspid
valves.4 Isolated mitral valvular injury usually has
more serious hemodynamic consequences than iso-
lated injury of the tricuspid valve.5 Mitral valvular
injury may consist of papillary muscle rupture, chor-
dae tendineae rupture, and laceration of the valve
leaflets.6 Papillary muscle rupture may be partial,
469.e1
 Journal of the American Society of Echocardiography
469.e2 Cordovil et al April 2006

Figure A and B, Transesophageal (TE) echocardiogram showing ruptured papillary muscle (arrows) from TE 4- and
2-chamber views. C, Color flow mapping depicting severe mitral regurgitation. D, Surgically resected anterior leaflet of
mitral valve with attached head of anterolateral papillary muscle. Note two additional ruptured pieces of muscle.

when involving one or more apical heads, or com-
plete, which involves entirely the muscle belly.7 The
mechanisms of papillary injury include compression
of the heart during late diastole or isovolemic con-
traction when the valves are about to close or just
closed.8 Significant thoracic compression increases
intracardiac pressure and most likely leads to severe
valve prolapse and rupture.9
The treatment for papillary muscle rupture con-
sists of different surgical approaches, such as mitral
valve replacement or, more recently, mitral annulo-
plasty, repair, and muscle reimplantation.9 In this
case, mitral valve replacement was the chosen tech-
nique because of the severity of anatomic distortion
and damage as observed by total laceration of pap-
illary muscle. Recently, Simmers et al10 reported that
only 25 cases of successful surgical repair of post-
traumatic mitral incompetence have been reported,
only 8 of which were caused by complete avulsion
of the anterolateral papillary muscle, as observed in
this case.
Physicians must be aware of the possibility of
associated cardiac injury in patients with nonpen-
etrating thoracic trauma.11 The severity of cardiac
trauma does not seem to be strictly related to chest
wall injury. In addition, severe mitral regurgitation
and subsequent congestive heart failure may occur
immediately after the chest injury or be delayed,
depending on the volume of blood regurgitation and
on left ventricular function, and can happen hours,
days, and even years after injury.
In the current case, the use of TEE was of utmost
importance to establish the diagnosis of mitral valve
papillary muscle rupture, despite the evidence of
systolic murmur. It is well established that TEE is a
safe and quick procedure performed at bedside, is
not affected by mechanical ventilation, and provides
important diagnostic information for patients in
intensive care as in the current case.11 Early diagno-
sis and prompt treatment may prevent fatal out-
come, and in this sense, the importance of TEE in
diagnosis of traumatic cardiac injury should be em-
Journal of the American Society of Echocardiography
Volume 19 Number 4
phasized. We wonder if TEE investigation should be
part of investigational strategy in patients with car-
diac trauma followed by cardiac decompensation.
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