Baruzzi A C, Knobel E, Cirenza C, Smith M R, Ozawa E, Gonçalves Júnior I, Akamine N, Fernandes Júnior C J
Hospital Israelita Albert Einstein, São Paulo.
Arq Bras Cardiol. 1994 Jul;63(1):39-44.
Three patients, two females, ages ranging from 62 to 78 years were studied, evolving with hypotension, acute pulmonary edema and cardiogenic shock. One had anterior myocardial infarction, and in two, infero-posterior. Due to severe hemodynamic instability and necessity of vasoactive drug therapy to maintain adequate arterial pressure, coronary angiography was performed in two, showing total occlusion of the circumflex artery and severe mitral regurgitation. In one case, angioplasty on the circumflex artery was successfully achieved. No hemodynamic improvement was observed, however. Doppler echocardiography depicted mild to moderate mitral regurgitation in the three cases. Transesophageal echo confirmed the clinical suspicion of papillary muscle rupture: total rupture of antero-lateral papillary muscle in one patient, as well as total and partial rupture of the postero-medial papillary muscle in the other two patients. Two patients were submitted to mitral valve replacement, and the surgical findings confirmed the transesophageal echo conclusions. One of them died in the immediate pos-operative period, whereas the other was discharged from the hospital and is doing well. The third patient died before operation. Differential diagnosis of acute mitral regurgitation due to papillary muscle dysfunction or rupture was not possible by left ventriculography or by transthoracic echo. Transesophageal echo was the only exam to clearly confirm papillary muscle rupture, as should be done promptly after clinical suspicion of this severe condition arises.
对3例患者进行了研究，其中2例为女性，年龄在62岁至78岁之间，均出现低血压、急性肺水肿和心源性休克。1例为前壁心肌梗死，2例为下后壁心肌梗死。由于严重的血流动力学不稳定以及需要使用血管活性药物治疗来维持足够的动脉压，对其中2例患者进行了冠状动脉造影，结果显示回旋支动脉完全闭塞以及严重的二尖瓣反流。在1例患者中，成功地对回旋支动脉进行了血管成形术。然而，未观察到血流动力学改善。多普勒超声心动图显示3例患者均有轻度至中度二尖瓣反流。经食管超声心动图证实了临床对乳头肌破裂的怀疑：1例患者前外侧乳头肌完全破裂，另外2例患者后内侧乳头肌完全或部分破裂。2例患者接受了二尖瓣置换术，手术结果证实了经食管超声心动图的结论。其中1例患者在术后即刻死亡，而另1例患者出院，情况良好。第3例患者在手术前死亡。通过左心室造影或经胸超声心动图无法对因乳头肌功能障碍或破裂导致的急性二尖瓣反流进行鉴别诊断。经食管超声心动图是唯一能够明确证实乳头肌破裂的检查方法，在临床怀疑出现这种严重情况后应立即进行检查。
