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The papillary muscles are an integral part of the heart's ventricles, with five in total: three in the right ventricle and two in the left. They are responsible for maintaining cardiac valvular function and preventing ventricular blood regurgitation. Papillary muscle rupture is a rare but severe complication, often resulting from myocardial infarction, trauma, or infective endocarditis. This rupture can lead to severe mitral valve regurgitation, causing cardiogenic shock and pulmonary edema. Surgical intervention is critical for timely treatment and reducing mortality rates. Papillary muscle realignment through pledget mattress stitching is one surgical option for treating left ventricular outflow tract obstruction caused by pathological papillary muscle orientation.
| Characteristics | Values |
|---|---|
| Location | Ventricles of the heart |
| Number | 5 in total: 3 in the right ventricle and 2 in the left ventricle |
| Names | Anterior, posterior, septal, anterolateral, posteromedial |
| Function | Prevent inversion or prolapse of atrioventricular valves on systole |
| Contraction | Shortly before ventricular systole, maintaining tension throughout |
| Rupture | Caused by myocardial infarction, blunt chest trauma, myocardial ischemia, trauma, infective endocarditis, syphilis, periarteritis nodosa, vegetative valvulitis, myocardial abscess, iatrogenic injury, cocaine use |
| Dysfunction | Caused by ischemia |
| Surgical treatment | Papillary muscle realignment via pledget mattress stitching, surgical resection |
| Imaging | Cardiovascular magnetic resonance (CMR), two-dimensional echocardiography |
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What You'll Learn
Papillary muscle rupture
There are five papillary muscles in the heart, three in the right ventricle (anterior, posterior, and septal) and two in the left ventricle (anterolateral and posteromedial). The anterolateral muscle receives blood from two sources, while the posteromedial muscle is supplied solely by the posterior descending coronary artery. This single blood supply makes the posteromedial muscle more vulnerable to ischemic episodes and rupture following a myocardial infarction.
Rupture of the papillary muscles can also occur due to myocardial ischemia, trauma, or infective endocarditis. Dysfunction of the papillary muscles causes blood to regurgitate through the valves, leading to backflow that can result in left- or right-sided heart failure. Papillary muscle rupture was first described in literature in 1948, and its visualization through two-dimensional echocardiography was achieved in 1981. Transesophageal echocardiography was introduced to identify the condition in 1985.
Surgical considerations for papillary muscle rupture include pathologic abnormalities that lead to left ventricular outflow tract obstruction. Surgical resection has been shown to significantly improve clinical outcomes. Another surgical option is papillary muscle realignment through pledget mattress stitching for left ventricular outflow tract obstruction caused by abnormal papillary muscle orientation.
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Papillary muscle abnormalities
The papillary muscles are muscles located in the ventricles of the heart. There are five total papillary muscles in the heart: three in the right ventricle and two in the left ventricle. They attach to the cusps of the atrioventricular valves (also known as the mitral and tricuspid valves) via the chordae tendineae. The contraction of the papillary muscles prevents inversion or prolapse of the valves on systole (or ventricular contraction).
Hypertrophic cardiomyopathy (HCM) is a common genetic heart disease with a prevalence of 1:200 in the general population. Papillary muscle abnormalities are often seen in HCM patients, including anterior and/or apical displacement, hypertrophy, bifidity, presence of accessory PM, and direct insertion into the anterior mitral valve leaflet. These abnormalities can contribute to left ventricular outflow tract (LVOT) obstruction, which should be addressed when treating HCM patients.
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Surgical considerations
Papillary muscle rupture is a rare complication, estimated to occur in 1% to 5% of patients with acute myocardial infarction. It carries a high mortality rate, with an estimated 50% mortality within 24 hours in cases of complete rupture. Thus, timely intervention is crucial to prevent severe complications and improve patient outcomes.
When a papillary muscle rupture is suspected, immediate consultation with cardiology and cardiothoracic surgery is necessary. The best initial study for identification in an unstable patient is transthoracic echocardiography, which has a sensitivity of 65% to 85% for visualizing structural abnormalities. Echocardiography is superior to cardiac catheterization as muscle ruptures may be diagnosed with minimal risk to the patient.
In cases of severe mitral regurgitation secondary to papillary muscle tear, surgical correction is often necessary. However, due to the high mortality rate associated with surgery, non-surgical interventions such as cardiac rehabilitation and device therapy may be considered first. Valve repair or replacement procedures require careful consideration of the papillary muscles' integrity and function, and ongoing research aims to establish best practices for preserving papillary muscle function during surgery.
In the context of mitral valve regurgitation, surgical relocation of the posterior papillary muscle has been studied as a potential treatment option. This procedure has been found to be effective in patients with a severely dilated left ventricle or regional left ventricular geometric changes causing mitral regurgitation. Papillary muscle repositioning has been proposed as a safe and long-lasting technique to repair complex injuries, with excellent clinical and echocardiographic results over the long term.
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Cardiac plexus fibres
The cardiac plexus is a network of nerves situated at the base of the heart that innervates the heart. It is divided into a superficial part and a deep part. The superficial part lies in the concavity of the aortic arch, and the deep part is situated between the aortic arch and the trachea. The two parts are closely connected.
The cardiac plexus contains both sympathetic and parasympathetic components. The sympathetic component of the cardiac plexus comes from cardiac nerves, which originate from the sympathetic trunk. The parasympathetic component originates from the cardiac branches of the vagus nerve. The superficial part of the cardiac plexus is formed by the superior cervical cardiac branch of the left sympathetic trunk and the inferior cardiac branch of the left vagus nerve.
The branches from the right half of the deep part of the cardiac plexus pass in front of and behind the right pulmonary artery. Those in front transmit filaments to the anterior pulmonary plexus and are then continued to form part of the anterior coronary plexus. Those behind the pulmonary artery distribute filaments to the right atrium and are then continued to form part of the posterior coronary plexus.
The left half of the deep part of the plexus is connected with the superficial part of the cardiac plexus, and gives filaments to the left atrium and to the anterior pulmonary plexus. It then forms the greater part of the posterior coronary plexus.
The cardiac plexus plays an important role in regulating the function of the heart. Injury to the cardiac plexus or its contributories can impair the function of the heart. Damage to the vagus nerves, which provide parasympathetic innervation, will affect the ability to decrease the heart rate, leading to tachycardia. Similarly, damage to the sympathetic fibres contributing to the cardiac plexus can reduce the ability to increase heart rate, causing bradycardia.
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Papillary muscle development
The papillary muscles are pillar-like muscles located in the ventricles of the heart. There are five papillary muscles in the heart: three in the right ventricle and two in the left ventricle. The papillary muscles of the left ventricle play an important role in the functioning of the mitral valve.
The left ventricle typically has two papillary muscles: the anterolateral and posteromedial muscles. However, studies indicate that 46% of hypoplastic and 18% of borderline left ventricle cases have just one papillary muscle. The anterolateral papillary muscle has a dual blood supply in 71% of patients, providing increased protection against ischemia. In contrast, the posteromedial papillary muscle has a single blood supply in 63% of patients, making it more susceptible to rupture following a myocardial infarction.
The papillary muscles of both the right and left ventricles contract shortly before ventricular systole and maintain tension throughout. This prevents regurgitation, or the backward flow of ventricular blood into the atrial cavities, by bracing the atrioventricular valves against prolapse. Papillary muscle rupture can occur due to myocardial infarction, blunt chest trauma, or other causes. Dysfunction can be caused by ischemia or other factors. Rupture and dysfunction can lead to severe mitral regurgitation and potentially fatal complications such as cardiogenic shock and pulmonary edema.
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Frequently asked questions
Papillary muscles are pillar-like muscles found in the ventricles of the heart. They play an important role in maintaining cardiac valvular function.
There are five papillary muscles in the heart: three in the right ventricle (anterior, posterior, and septal) and two in the left ventricle (anterolateral and posteromedial).
Papillary muscles contract to prevent inversion or prolapse of the atrioventricular valves during systole, which stops blood from flowing back into the atrial cavities.
Papillary muscle rupture is a rare but severe complication that typically occurs after a myocardial infarction or due to infective endocarditis. It can also be caused by chest trauma or myocardial ischemia.
Papillary muscle rupture is a medical emergency that requires immediate medical intervention. Surgical treatment options include surgical resection and papillary muscle realignment via pledget mattress stitching.
