CRP1.A Case of Tricuspid Valve Ischemic Papillary Muscle Rupture Repair Assisted by Temporary Mechanical Circulatory Support

Los Angeles Convention Center 

A 69-year-old male with a history of non-ischemic cardiomyopathy, mild non-obstructive coronary artery disease, an implantable cardiac resynchronization therapy defibrillator (CRT-D) and atrial fibrillation, presented to the emergency room with progressive shortness of breath after recently undergoing atrioventricular node ablation. On physical examination, vital signs were normal with edematous face, basal crackles, elevated jugular venous pressure and lower limb edema. Laboratory tests confirmed increased troponin I, creatinine and brain natriuretic peptide (BNP). Transthoracic echocardiography revealed left ventricular ejection fraction (LVEF) of 15%, preserved right ventricular systolic function, mild mitral regurgitation, and flail anterior leaflet of tricuspid valve attached to a ruptured segment of the anterior papillary muscle resulting in severe tricuspid regurgitation. Coronary angiogram demonstrated chronic total occlusion of the proximal left anterior descending artery (LAD) and non-obstructive lesions in the left circumflex and right coronary arteries. Given the patient's age and minimal comorbidities, a surgical repair was planned with standby mechanical circulatory support. Tricuspid valve repair was performed and consisted of reimplantation of the papillary muscle, placement of a neo-chord to the anterior leaflet, and placement of a size 32 semirigid annuloplasty ring. Two coronary bypass grafts were performed, with left internal mammary artery to LAD and vein graft to the second obtuse marginal. Following slow weaning from cardiopulmonary bypass (CPB), transesophageal echocardiography revealed new central severe mitral regurgitation and dilated mitral annulus, likely resulting from improved forward flow through the tricuspid valve and right ventricle. This necessitated mitral repair with reduction annuloplasty using a size 32 ring, with a good result. Upon weaning off CPB, it was evident that left ventricular function is markedly reduced with minimal right ventricular dysfunction. It was decided that to provide hemodynamic support and be able to wean the patient off CPB, insertion of Impella 5.0 was required. This was performed through a 10mm graft sewn to the right axillary artery with excellent flow. The Impella was weaned and removed on the third postoperative day after which the patient recovered slowly. Finally, a transthoracic echocardiogram demonstrated intact repair and mild improvement in LVEF to 25% upon 6 months follow-up.