Morphological Assessment and Possible Clinical Implications of the Left Ventricle Papillary Muscles. Study in a Colombian Population Sample

SUMMARY: Papillary muscles in the left ventricle present multiple anatomic expressions that are relevant for medical fields focusing on the understanding of clinical events involving these structures. Here, the aim was to perform a morphological characterization of the left ventricle papillary muscles in a sample of Colombian population. In the study were included eighty-two hearts from male individuals who underwent autopsy at the Institute of Legal Medicine and Forensic Sciences in Bucaramanga, Colombia. In each heart was carefully performed a longitudinal incision on the obtuse margin to visualize the papillary muscles. Data set was registered, and analysis of the continuous and categorical variables was carried out. Single anterior papillary muscle was observed in 74 samples (90.2 %) whereas this represented only 48 specimens (58.5 %) for the posterior papillary muscle (p = 0.3). Mean length and breadth of the anterior muscle were 29.9 ± 4.94 and 11.74 ± 2.75 mm, and those for the posterior muscle were 27.42 ± 7.08 and 10.83 ± 4.08 mm. Truncated apical shape was the most frequent type observed on the papillary muscles, anterior 41 (50 %) and posterior 37 (45.1 %), followed by flat-topped in the anterior 25 (30.5 %) and bifurcated in posterior muscle 14 (17.1 %). A mean of 9.04 ± 2.75 chordae raised from the anterior and 7.50 ± 3.3 from posterior papillary muscle. In our study we observed a higher incidence of single papillary muscles and slightly larger dimensions than information reported in the literature. The anatomic diversity of the papillary muscles should be considered for the correct image interpretation, valve implantation and performance evaluation on myocardial ischemic events.

Los músculos papilares del ventrículo izquierdo presentan múltiples expresiones anatómicas que son relevantes para las áreas médicas que se centran en la comprensión de los eventos clínicos que involucran estas estructuras. El objetivo fue realizar una caracterización morfológica de los músculos papilares del ventrículo izquierdo en una muestra de población colombiana. En el estudio se incluyeron ochenta y dos corazones de individuos masculinos a los que se les realizó autopsia en el Instituto de Medicina Legal y Ciencias Forenses de Bucaramanga, Colombia. En cada corazón se realizó cuidadosamente una incisión longitudinal en el margen obtuso para visualizar los músculos papilares. Se registró el conjunto de datos y se realizó el análisis de las variables continuas y categóricas. Se observó un solo músculo papilar anterior en 74 muestras (90,2 %), mientras que este rasgo se presentó en 48 muestras (58,5 %) para el músculo papilar posterior (p = 0,3). La longitud y anchura media del músculo anterior fueron 29,9 ± 4,94 y 11,74 ± 2,75 mm, y las del músculo posterior fueron 27,42 ± 7,08 y 10,83 ± 4,08 mm. La forma apical truncada fue el tipo más frecuente observado en los músculos papilares, anterior 41 (50 %) y posterior 37 (45,1 %), seguido de la forma plana en los 25 anteriores (30,5 %) y bifurcada en el músculo posterior 14 (17,1 %). Una media de 9,04 ± 2,75 cuerdas elevadas desde el músculo papilar anterior y 7,50 ± 3,3 desde posterior. En nuestro estudio observamos una mayor incidencia de músculos papilares únicos y dimensiones ligeramente mayores que la información reportada en la literatura. La diversidad anatómica de los músculos papilares debe ser considerada para la correcta interpretación de imágenes, implantación valvular y evaluación del desempeño en eventos isquémicos miocárdicos.

Acute inferior myocardial infarction combined with papillary muscle rupture: A case report / 中南大学学报(医学版)

The incidence of acute myocardial infarction (AMI) is increasing. Acute papillary muscle rupture is one of the serious and rare mechanical complications of AMI, which occurs mostly in inferior and posterior myocardial infarction. A patient with acute inferior myocardial infarction developed pulmonary edema and refractory shock, followed by cardiac arrest. After cardiopulmonary resuscitation (CPR), revascularization of criminal vessels was carried out by emergency percutaneous transluminal coronary angioplasty (PTCA) under the support of intra-aortic balloon pump (IABP) and extra corporeal membrane oxygenation (ECMO). Although the patient was given a chance for surgery, his family gave up treatment due to unsuccessful brain resuscitation. It reminds that mechanical complications such as acute papillary muscle rupture, valvular dysfunction and rupture of the heart should be highly suspected when cardiogenic pulmonary edema and cardiogenic shock are difficult to correct in acute inferior myocardial infarction. Echocardiogram and surgery should be put forward when revascularization of criminal vessels is available.

Primer caso en Colombia de crioablación y mapeo de alta densidad en arritmia ventricular del músculo papilar / First case in Colombia of cryoablation and high-density mapping in ventricular arrhythmia of the papillary muscle

Resumen La ablación con catéter se ha convertido en un enfoque práctico para el tratamiento de las arritmias cardiacas, sobre todo cuando el manejo farmacológico óptimo no logra controlarlas. De esta manera se reduce la readmisión hospitalaria y se mejora la calidad de vida de los pacientes, incluso de aquellos en quienes no se logra la resolución completa de la arritmia. Hasta la fecha se han utilizado varias modalidades entre las que se incluyen la radiofrecuencia y la crioablación. Los principios de la criobiología se establecieron por primera vez con investigaciones sobre la congelación de los tumores y datos actuales sugieren que es necesaria una temperatura entre -30 a -40 °C para inducir muerte celular, ya sea por mecanismos inmediatos, como ruptura celular, lesión hipotérmica o daño vascular, o tardíos, como apoptosis. Se presenta el primer caso en Colombia de mapeo de alta densidad y crioablación como estrategias combinadas para el tratamiento efectivo de un paciente con alta carga de arritmia ventricular sintomática originada en el músculo papilar anterolateral, sin recurrencia de la arritmia en el tiempo de seguimiento.

Abstract Catheter ablation has become a practical approach for the treatment of cardiac arrhythmias, especially when optimal pharmacological management does not achieve adequate control of it, thus reducing hospital readmission and improving quality of life, even in patients in whom the complete resolution of the arrhythmia is not achieved. To date, a variety of modalities have been used, including radiofrequency and cryoablation. The principles of cryobiology were established for the first time with research on the freezing of tumors and current data suggest that a temperature of -30 to -40 °C is necessary to induce cell death either by immediate or delayed mechanisms; immediate as cellular rupture or hypothermic injury as well as vascular damage or apoptosis among the late. The first case in Colombia of high-density mapping and cryoablation is presented as combined strategies for the effective treatment of a patient with a high load of symptomatic ventricular arrhythmia originating in the anterolateral papillary muscle, without recurrence of the arrhythmia at the time of follow-up with symptoms, so it was to successful cryoablation, as the first case with this technique.

Successful Mitral Valve Repair for Papillary Muscle Rupture Caused by Coronary Spasm Induced by Myocardial Infarction / 日本心臓血管外科学会雑誌

Papillary muscle rupture, a complication of acute myocardial infarction, causes acute mitral valve regurgitation. However, to date, only a few articles have reported PMR associated with coronary spasm. In this article, we report the case of a 64-year-old woman who suffered posteromedial papillary muscle rupture caused by coronary spasm or Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA), and was successfully treated with mitral valve repair.

A Case of Left Ventricular Free Wall Rupture with Suspected Posterior Papillary Muscle Necrosis / 日本心臓血管外科学会雑誌

We report a case of arbitrary delayed surgical repair for left ventricular free wall rupture (LVFWR) after acute myocardial infarction with suspected posterior papillary muscle necrosis. The case was a 67-year-old woman who had chest and back pain in the morning, and relapsed in the evening, and was urgently transported. She had an acute lateral wall myocardial infarction on an electrocardiogram and pericardial effusion on transthoracic echocardiography (TTE). She was found to have an obstruction at the origin of the left circumflex branch on coronary angiography. TTE showed low-intensity findings on the head of the posterior papillary muscle, suggesting necrosis of the papillary muscle. For LVFWR, conservative treatment was prioritized and IABP (intra-aortic balloon pumping) management was performed for the purpose of reducing after load because there was concern about papillary muscle rupture (PMR) due to cardiac manipulation and because it was an oozing type and did not disrupt respiratory of circulatory dynamics. On the 7th day after the onset, TTE showed improvement in echo-luminance of the posterior papillary muscle head and gradual increase in pericardial fluid, and a non-suture procedure was performed. She withdrew from the IABP on the third day after surgery and was discharged home on the 12th day.

Cenário Disfuncional dos Principais Componentes Responsáveis pelo Equilíbrio do Trânsito de Cálcio Miocárdico na Insuficiência Cardíaca Induzida por Estenose Aórtica / The Dysfunctional Scenario of the Major Components Responsible for Myocardial Calcium Balance in Heart Failure Induced by Aortic Stenosis

Resumo Fundamento O remodelamento cardíaco patológico se caracteriza por disfunção diastólica e sistólica, levando à insuficiência cardíaca. Neste contexto, o cenário disfuncional do trânsito de cálcio miocárdico (Ca2+) tem sido pouco estudado. Um modelo experimental de estenose aórtica tem sido extensamente utilizado para aprimorar os conhecimentos sobre os principais mecanismos do remodelamento patológico cardíaco. Objetivo Entender o processo disfuncional dos principais componentes responsáveis pelo equilíbrio do cálcio miocárdico e sua influência sobre a função cardíaca na insuficiência cardíaca induzida pela estenose aórtica. Métodos Ratos Wistar de 21 dias de idade foram distribuídos em dois grupos: controle (placebo; n=28) e estenose aórtica (EaO; n=18). A função cardíaca foi analisada com o ecocardiograma, músculo papilar isolado e cardiomiócitos isolados. No ensaio do músculo papilar, SERCA2a e a atividade do canal de Ca2+ do tipo L foram avaliados. O ensaio de cardiomiócitos isolados avaliou o trânsito de cálcio. A expressão proteica da proteínas do trânsito de cálcio foi analisada com o western blot. Os resultados foram estatisticamente significativos quando p <0,05. Resultados Os músculos papilares e cardiomiócitos dos corações no grupo EaO demonstraram falhas mecânicas. Os ratos com EaO apresentaram menor tempo de pico do Ca2+, menor sensibilidade das miofibrilas do Ca2+, prejuízos nos processos de entrada e recaptura de cálcio pelo retículo sarcoplasmático, bem como disfunção no canal de cálcio do tipo L (CCTL). Além disso, os animais com EaO apresentaram maior expressão de SERCA2a, CCTL e trocador de Na+/Ca2+. Conclusão Insuficiência cardíaca sistólica e diastólica devido à estenose aórtica supravalvular acarretou comprometimento da entrada de Ca2+ celular e inibição da recaptura de cálcio pelo retículo sarcoplasmático devido à disfunção no CCTL e SERCA2a, assim como mudanças no trânsito de cálcio e na expressão das principais proteínas responsáveis pela homeostase de Ca2+ celular.

Abstract Background Maladaptive cardiac remodelling is characterized by diastolic and systolic dysfunction, culminating in heart failure. In this context, the dysfunctional scenario of cardiac calcium (Ca2+) handling has been poorly studied. An experimental model of aortic stenosis has been extensively used to improve knowledge about the key mechanisms of cardiac pathologic remodelling. Objective To understand the dysfunctional process of the major components responsible for Ca2+ balance and its influence on cardiac function in heart failure induced by aortic stenosis. Methods Male 21-day-old Wistar rats were distributed into two groups: control (sham; n= 28) and aortic stenosis (AoS; n= 18). Cardiac function was analysed by echocardiogram, isolated papillary muscle, and isolated cardiomyocytes. In the papillary muscle assay, SERCA2a and L-type Ca2+ channel activity was evaluated. The isolated cardiomyocyte assay evaluated Ca2+ handling. Ca2+ handling protein expression was analysed by western blot. Statistical significance was set at p <0.05. Results Papillary muscles and cardiomyocytes from AoS hearts displayed mechanical malfunction. AoS rats presented a slower time to the Ca2+ peak, reduced Ca2+ myofilament sensitivity, impaired sarcoplasmic reticulum Ca2+ influx and reuptake ability, and SERCA2a and L-type calcium channel (LTCC) dysfunction. Moreover, AoS animals presented increased expression of SERCA2a, LTCCs, and the Na+/Ca2+ exchanger. Conclusion Systolic and diastolic heart failure due to supravalvular aortic stenosis was paralleled by impairment of cellular Ca2+ influx and inhibition of sarcoplasmic reticulum Ca2+ reuptake due to LTCC and SERCA2a dysfunction, as well as changes in Ca2+ handling and expression of the major proteins responsible for cellular Ca2+ homeostasis.

Disparity In Morphology Of Papillary Muscles Of The Mitral Valve Complex With Surgical Significance

Background: The mitral valve apparatus, consisting of the mitral valve leaflets and commissures and subvalvular apparatus- papillary muscles and chordae tendinae; is one of the most complex and intricately designedstructures present in the human body and therefore the understanding of anatomical variations of papillarymuscles becomes important for surgical interventional procedures, in response to the increasing incidence ofvalvular heart defects. The aim of the cadaveric analysis was to identify the disparity in the morphometry of thepapillary muscles of the mitral valve complex. Therefore this study was taken up with an effort to extend theconcepts previously presented as well as to overcome deficiencies in the knowledge of gross architecture andpositional nomenclature of the papillary muscles.Materials and methods: Fifty formalinized cadaveric hearts were the material for study. Papillary muscles of leftventricle were classified according to a system developed by Berdajs et al., (2005), by precisely measuringshapes lengths and widths.Results: The significant outcome of this study indicates that no two papillary muscles out of the 50 specimenshad the same size, shape or position. All the hearts had two distinct groups of muscles – anterolateral andposteromedial. Specific analysis of each group revealed data regarding the muscles. In the antero-lateral groupof the specimens, the maximum height and width of the muscles was 37.40mm and 17.06mm respectively and inthe postero-lateral group, 33.86 and 26.90mm respectively. Conical shaped muscles were the most commonlyfound muscles owing to the minimum obstruction posed by them to blood flow.Implication: Better understanding of morphological variations can help cardiothoracic surgeons to customizesurgical procedures according to the papillary muscle pattern of the individual patient

Regulatory effect of epinephrine on major ion channels in repolarization of ventricular papillary muscle cells / 中国药理学通报

In some states such as myocardial ischemia, heart failure, angina pectoral and myocardial ion channel disease and so on, one person may catch with a rapid cardiac arrhythmia, e-ven a generate ventricular fibrillation or a sudden death, especially in the case of emotional agitation, stress or sympathetic tone increasing abnormally, and exogenous administration of epinephrine , followed by a significant rising of catecholamine. All the above have a relationship with the sympathetic excitatory for ct and p receptors, the regulation of myocardial ion channel function, changing the myocardial action potential, and the myo cardial excitability. From the perspective of myocardial electro-physiology , this paper analyzes the effect of adrenal receptors on the regulation of ion channels, which plays a main action in the myocardial depolarization process, as well as the effect on the action potential duration, aiming to deepen the understanding of the mechanism of catecholamine inducing ventricular arrhythmias.

A Comparative Study Of Number And Position Of Papillary Muscles And Clinical Significance

Introduction: Papillary muscles are the conical muscle masses project into the cavity of ventricle and areinserted into the valve cusps by chordae tendinae. They prevent the cusps from being forced back into the atriumduring ventricular contraction. Their number and positions are highly variable. An anomalous papillary musclecan act as an ectopic foci. Hence these variations should be assessed before any operative intervention on thevalve. Present study aim to analyse these variations in detail.Materials and Methods: This is a descriptive observational study to analyse the variations in number andposition of papillary muscles in ventricles of 100 adult human hearts ranging in age from 17 to 80 yearsobtained from autopsy specimens. The methodology used was the dissection method according to standardautopsy techniques. The data obtained were quantified as frequencies (in %).Results: Of the 100 hearts studied, the right ventricle consisted of the usual three groups of papillary muscles in84% of hearts whereas the remaining 16% of hearts had only two groups (rudimentary SPMs). The left ventricleconsisted of two groups of papillary muscles in 73% of hearts ; three groups in 23%; four groups in 4% and noneof the hearts contained single papillary muscle. Regarding the positions, the right ventricle had APMs inanterobasal position, the PPMs in posterobasal position and SPMs was located close to ventricular septum andno extra group of papillary muscles were found. In left ventricle, 73% of hearts had APMs and PPMs in anterolateraland posteromedial positions respectively, whereas in 27% (23% and 4%) hearts, the extra group of papillarymuscles (third group and fourth group) were interlinked to PPMs and was situated in posterolateral position.Conclusion: These findings suggest that the variations in number and positions of papillary muscles should beanticipated before any operative intervention on the valvular apparatus.

Expression of SOCS1 in overload papillary muscles of mice cardiac ventricle / 国际生物医学工程杂志

Objective Toinvestigatetheexpressionofsuppressorofcytokinesignaling1(SOCS1)inoverloaded ventricle papillary muscle, so as to understand its expression characteristics in structural remodeling after the overloading and the biomechanical properties of the muscle under cubic jellyfish toxin-1(CfTX-1) pretreatment that can affect cell signal transduction. Methods Abdominal aortic-venous fistula (AVF) were operated in Kunming mice (n=5), and the cardiac left ventricles were harvested after two weeks of fistulation. The mice in normal group were sham operated as a control (n=5). In vitro culture, the left ventricular papillary muscle of normal mice was used (n=20). In the stretching group, the isolated papillary muscles were double-ratio stretched and fixed on silicone plate. In the relaxation group, the muscles were not stretched. A separated subgroup that transfected with SOCS1 plasmids were set in each group of stretching and relaxation. The papillary muscle samples of each group were cultured in culture medium for 3 days at 37 ℃, and then homogenized for extracting total protein. The total protein was separated by 10％ sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The 23 ku band with SOCS1 was used as the target band, and the integrated optical density (IOD) value was measured by computer image analysis method. The expression of SOCS1 protein was detected by Western Blot and the imprinted IOD value was also measured. The papillary muscle in the stretching group was stretched by micro-positioned stretching method, and the initial load was 1 g. After stabilization, the papillary muscle was stretched by 15 mm for continuously 5 times, and the passive tension characteristic curves during the first and fifth stretching were observed and recorded. The peak passive tension (PTmax) and its deceleration velocity (DV) of the papillary muscle were calculated based on the curves. Results Comparing with the AVF group, the normal group had higher IOD values of 23 ku band and SOCS1 blot in total protein of the papillary muscle, and the differences were statistically significant (all P<0.01). The IOD value of 23 ku band in the SOCS1 transfected stretching group was significantly higher than those of the two relaxation groups, and the differences were statistically significant (all P<0.01). However, the difference of this value was not statistically significant between the two relaxation groups. The average IOD value of SOCS1 blot in the SOCS1 transfected stretching group was higher than those of the normal stretching group and the SOCS1 transfected relaxation group, and the differences were statistically significant (all P<0.01). Comparing with the normal group, the AVF group had higher PTmax and ultimate PTmax of the papillary muscles, and had a lower DV values, and the differences were statistically significant (all P<0.01). Conclusions The expression of SOCS1 is sensitive to tension load, and has a positive effect as an overload-sensitive signal in improving myocardial adaptability, protecting myocardial structure and maintaining systolic and diastolic function. CfTX-1 also has a positive effect on improving the compliance of ventricular papillary muscles.

Evaluation of papillary muscles function in myocardial infarction patients using 2D speckle tracking imaging / 中华超声影像学杂志

Objective To investigate papillary muscle function and construction in myocardial infarction(MI) patients by two-dimensional speckles tracking imaging(2D-STI),and to analyze the influence factors of ischemic mitral regurgitation.Methods Fifty myocardial infarction with ischemic mitral regurgitation(IMR) patients were brought into case group.The patients were divided into two groups:Ant MI group and Inf-Pos-MI group.Forty-five health volunteers were involved as control group.Anterior,posterior papillary muscle longitudinal strain (ALS,PLS),delay time(DT),fractional shortening (FS),length between the posterior or anterior papillary muscle tips and the contralateral anterior mitral annualr (APM AMA,PPM AMA),mitral leaflet closure (MLC),inter distance papillary muscle (IPMD) were aquired respectively.Papillary muscle function and construction among the groups were compared,and the effective factors of IMR were evaluated.Results Between the control group and Ant-MI group,the left ventricular end-diastolic diameter(LVEDD),left ventricular end-diastolic and end-systolic volume(LVEDV,LVESV),left ventricular ejection fraction(LVEF),ALS,delay time(DT),A FS,IPMD,MLC,APM-AMA,PPM-AMA were significantly different(all P ＜0.05).Between the control group and Inf-Pos-MI group the LVEDD,LVEDV,LVESV,EF,DT,PPM-AMA,MLC,PLS,P-FS were significantly different(P ＜0.05).Between the Ant-MI group and Inf-Pos-MI group,the LVEDD,LVEDV,LVESV,EF,MLC,ALS,PPM-AMA,PLS were significantly different (all P ＜ 0.05).In the Ant-MI group,LVEDV,ALS,MLC were significantly correated with Gensini score(r =0.71,-0.65,0.56;P ＜0.05).In the Inf-Pos-MI group,PPM AMA,PLS were significantly correated with Gensini score(r =0.65,-0.76;P ＜0.05).In the Ant MI group and Inf-Pos-MI group,the ALS,PLS,PPM-AMA were significantly different (P ＜ 0.05).Its correlates in Logistic analysis of Ant-MI group included LVEDV,MLC,DT with OR 1.48,1.72,1.54(P ＜0.05),respectively.Its correlates in logistic analysis of Inf Pos-MI group included PLS,PPM-AMA,DT with OR 1.78,1.57,1.56 (P ＜0.05),respectively.Conclusions There are different extent of damage of papillary muscle function and construction in Ant-MI group and Inf-Pos-MI group.The increases of LVEDV and MLC and desynchronization of PMs are risk factors of IMR in Ant-MI group.The increases of PMP-AMA,decrease PLS and desynchronization of PMs are risk factors of IMR inInf-Pos-MI group.

Prompt diagnosis of ST-elevation myocardial infarction with papillary muscle rupture by point-of-care ultrasound in the emergency department

A previously healthy 61-year-old man presented to the emergency department with chest pain and dyspnoea for 6 hours. Examination revealed distress with an apical pansystolic murmur. Initial electrocardiogram showed sinus tachycardia and ST elevation in leads II, III, and aVF compatible with an inferior ST-elevation myocardial infarction. Point-of-care echocardiography in the emergency department showed a flail anterior mitral leaflet and severe mitral regurgitation, leading to a provisional diagnosis of papillary muscle rupture. Emergency cardiac catheterization showed 100%, 80%, and 70% occlusion of the middle right coronary, left anterior descending, and left circumflex arteries, respectively. An emergency triple vessel coronary artery bypass grafting and mitral valve replacement was performed. Posteromedial papillary muscle rupture resulting in mitral regurgitation was confirmed intraoperatively. The patient recovered uneventfully. In the absence of primary percutaneous coronary intervention, thrombolysis decisions should be made with extreme caution if mechanical complications of ST-elevation myocardial infarction are suspected.

Importance of SERCA2a on early isolated diastolic dysfunction induced by supravalvular aortic stenosis in rats

Cardiac remodeling is defined as changes in shape and function of the heart in response to aggression (pressure overload). The sarcoplasmic reticulum calcium ATPase cardiac isoform 2a (SERCA2a) is a known factor that influences function. A wide spectrum of studies report a decrease in SERCA2a in heart failure, but none evaluate it's the role in early isolated diastolic dysfunction in supravalvular aortic stenosis (AoS). Our hypothesis was that SERCA2a participates in such dysfunction. Thirty-day-old male Wistar rats (60-80 g) were divided into AoS and Sham groups, which were submitted to surgery with or without aorta clipping, respectively. After 6 weeks, the animals were submitted to echocardiogram and functional analysis by isolated papillary muscle (IPM) in basal condition, hypoxia, and SERCA2a blockage with cyclopiazonic acid at calcium concentrations of 0.5, 1.5, and 2.5 mM. Western-blot analyses were used for SERCA2a and phospholamban detection. Data analysis was carried out with Student's t-test and ANOVA. AoS enhanced left atrium and E and A wave ratio, with preserved ejection fraction. Basal condition in IPM showed similar increases in developed tension (DT) and resting tension (RT) in AoS, and hypoxia was similar between groups. After cyclopiazonic acid blockage, final DT was equally decreased and RT was similar between groups, but the speed of relaxation was decreased in the AoS group. Western-blot was uniform in all evaluations. The hypothesis was confirmed, since functional parameters regarding SERCA2a were changed in the AoS group.

Clinical analysis of endoscopic papillary muscle incision combined with balloon dilation in the treatment of common bile duct stones in elderly patients / 中国基层医药

Objective To investigate the safety and efficacy of endoscopic duodenal papillary muscle small incision(EST)combined with duodenal papillary balloon dilation(EPBD)in the treatment of elderly patients with bile duct stones.Methods 100 elderly patients with bile duct stones were treated with endoscopic stone removal. Among them,55 patients were treated with SEST combined with EPBD(EPBD group),45 patients were treated with a single EST(EST group),the rate of stone removal,the occurrence rate of lithotripsy and the incidence of complications were compared between the two groups.Results The SEST +EPBD group at a time calculi clearance rate,postopera-tive hyperamylasemia,post pancreatitis,cholangitis were 98.2%,7.3% and 3.6%,1.8%,the EST group were 97.7%,6.7%,6.7%,3.6% and the difference between the two groups had no significant(all P >0.05).The SEST+EPBD group of gravel formation rate was 3.6%,lower than 13.3% in the EST group,the difference was statistically significant(χ2 =9.647,P <0.05).The SEST +EPBD group had no bleeding,bleeding in EST group incidence rate was 11.1%,the difference was statistically significant(χ2 =11.235,P <0.05);The recurrence rate of the SEST +EPBD group was 1.8%,which was lower than 11.1% in the EST group,the difference was statistically significant (χ2 =10.113,P <0.05 ).Conclusion EST combined with EPBD in the treatment of elderly common bile duct stones is safe and effective,which can significantly reduce the incidence of debris and bleeding,reduce the recurrence rate of common bile duct stones.

Clinical Feature Analysis of Papillary Muscle Hypertrophic Cardomyopathy in 21 Patients / 中国循环杂志

Objective: To explore the clinical and magnetic resonance imaging (MRI) features of papillary musclehypertrophic cardiomyopathy. Methods: Our research contained 2 groups: Papillary muscle hypertrophic cardiomyopathy group,n=21 patients treated in our hospital from 2013-01 to 2015-12 including 18 male and 3 female; Control group,n=50 subjects without cardiovascular disease those were conifrmed by our hospital at the same period of time. Clinical and MRI examinations were conducted in all patients, the ifndings were compared between 2 groups. Results: Compared with control subjects, papillary musclehypertrophic cardiomyopathy patients had the main symptoms of shortness of breath, chest tightness and pain; associated with systolic murmur; ECG could be normal or with T wave inversion; cardiac MRI showed that 1/2 papillary muscle diameter>1.1cm. Blood levels of triglyceride, left atrial diameter, inter-ventricular septum thickness, the values of E/A and EDT were statistically different between 2 groups, allP<0.05. Conclusion: Clinical features of papillary muscle hypertrophic cardiomyopathy were lack of speciifcity, the morbidity and clinical signiifcance should be further investigated.

Morphometric and Clinical Analysis of Moderator Band in Humans.

Background: The moderator band has the right bundle of His within the right ventricle. It also is known to prevent the over dilatation of RV. It is important because of its involvement in RV infarcts, in differentiating RV from LV in congenital anomalies, in VPDs & VTs and in VSDs. The present literature is very much lacking in its morphometry. Materials and Methods: Moderator band was looked for in 50 hearts and only in this study did we find it in all the hearts. The length, the thickness, the distance from the tricuspid valve along with the presence of any trabeculations in the septal end or in the papillary muscle end were looked for and recorded. Results: The average length was 14.71±4.99mm, the average thickness was 4.97±1.64 mm, the average distance from the tricuspid orifice was 19.85±5.92 mm. The attachment to the anterior papillary muscle was found to be branched in 8 hearts that is having an incidence of 14% . The septal end were branched and separated as two in only two specimens. Only one specimen had branched attachments on both the apical and septal ends. Conclusion: The distance from tricuspid valve and knowledge of branching are important in corrective surgeries of the VSDs. An awareness of length and thickness helps the clinician to differentiate moderator band from the other structures, which may result in misdiagnosis during echocardiography. Its presence may in fact be of significance in preventing over distension of the heart in RV myocardial ischaemia.

A Morphological And Morphometric Study Of Right Ventricular Papillary Muscles In North Indian Region.

Abstracts: Background & Objective: Aim of present study was morphological and morphometric observation of papillary muscles of tricuspid valve of human heart. Methodology: This study was carried out in 36 human (24 males and 12 females) heart from adult cadavers, which were dissected according to standard technique. All papillary muscles were observed for their shapes, numbers and dimensions in centimeters. Data were tabulated and statistical comparison were done using “chi square” and “z” test. Results: The average length of anterior, posterior and septal papillary muscle was 1.42 ± 0.29 cm, 0.94 ± 0.23 cm and 0.18 ± 0.08 cm while average breadth of anterior, posterior and septal papillary muscle was 0.41± 0.12 cm, 0.29± 0.09 cm and 0.11± 0.01 cm respectively. The anterior papillary muscles presented 1 head in 27.78% and 2 heads in 25%, while posterior papillary muscles presented 1 head in 27.78% and 2 heads in 25%. All the septal papillary muscles presented with 1 head. Single anterior papillary muscle was found to be 97.22% while posterior papillary muscle was found to be single in 72.28% and double in 27.78. Septal papillary muscle was found to be single in 25% cases and absent in 38.89% cases. Conclusion: Data obtained from this study might be helpful for reparative surgical procedures of tricuspid valve.

Morphometric study on posterior papillary muscles of human tricuspid valve.

Background: Aim of the present study was to observe the measurements of posterior papillary muscles present in tricuspid valve of human heart. Measurements of posterior papillary muscles in tricuspid valve gains utmost importance in cardiac surgeries because they are the causes of myocardial infarction in recent times because of its variations and detection of these causes by advent in modern technologies which will help in treatment of tricuspid valve diseases. Material and methods: This study was carried out on 96 normal formalin fixed human heart specimens. Dissection was performed according to standard techniques. Posterior papillary muscles were observed and length, width and thickness of each muscle were measured and documented. Results: In the present study, numbers of posterior papillary muscles were present with a frequency of 0-7, with most common appearance of 2 muscles in 38 hearts (39.6%) and least common incidence of 0 muscles in 1 heart (1%). Posterior papillary muscles were present in 95 hearts, with maximum number of 7 muscles in 1 heart (1%) and minimum number of 1 muscle in 27 hearts (28.1%). In measurements of papillary muscles, posterior papillary muscle mean height was 1.05±0.37 cm, mean width was 0.63±0.17 cm and mean thickness was 0.5±0.11 cm respectively. Conclusion: This study serves to understand the morphometry of posterior papillary muscles better and can help in various surgical procedures and cardiac treatment done on tricuspid valve.

Cadaveric Study on Anterior and Posterior Papillary Muscles of Tricuspid Valve.

Background: Aim of the present study was to observe the morphology, measurements and types of papillary muscles present in tricuspid valve of human heart. Morphology, measurements and attachments of papillary muscles in tricuspid valve gains utmost importance in cardiac surgeries and causes of myocardial infarction in recent times because advent in modern technologies in treatment of tricuspid valve diseases. Materials andMethods: This studywas carried out on 96 normal fresh formalin fixed human post-mortemheart specimens. Hearts are not grouped into any criteria of sex and age. Dissection was performed according to standard techniques. Types of papillary muscles observed and length, width and thickness of each muscle are measured and documented. Results: In the present study, number of papillary muscles was present with a frequency of 2-10. Maximum numbers of papillary muscles were 10 seen in only one heart (1%) and minimum numbers of papillary muscles were 2 seen in 3 hearts (3.1%). Anterior papillary muscles were present in all 96 (100%) hearts. Maximum numbers of muscles observed were 3 seen in 6 hearts (6.3%) and minimum number muscle was 1 seen in 66 (68.8%) hearts, which was normal. Two papillary muscles were seen in remaining 24 hearts (25%). Posterior papillary muscles were present in 95 (98.95%) hearts. Seven papillary muscles were observed in only 1 (1%) heart and only 1 papillary muscle was seen in 27 (28.1%) hearts. In measurements of papillary muscles, anterior papillary muscle mean height was 1.49±0.44 cm; mean width was 0.82±0.21 cm and mean thickness was 0.64±0.15 cm respectively and posterior papillarymuscle mean height was 1.05±0.37 cm,mean width was 0.63±0.17 cm and mean thickness was 0.5±0.11 cm respectively. Conclusion: We hope this study will serve to understand the tricuspid valve complex and morphometry of different papillary muscles better and it will help in various surgical procedures and cardiac treatment done on tricuspid valve.

Mitral Valve Plasty in Postinfarction Partial Rupture of a Posterior Papillary Muscle / 日本心臓血管外科学会雑誌

We report the successful treatment of an 81-year-old woman after a difficult diagnosis of mitral valve regurgitation resulting from partial rupture of the posterior papillary muscle. The patient, with a chief complaint of dyspnea, was admitted to our hospital in October, 2010. Echocardiography revealed severe MR and an oscillating abnormal mass attached to the mitral posterior leaflet was assessed as vegetation. Her general condition worsened and coronary angiography revealed 90% stenosis at #6 and 99% stenosis at #12. Partial papillary muscle rupture of post acute myocardial infarction was ruled out. Urgent surgery was performed. It is found that tissue we had assessed as vegetation was a part of the posterior papillary muscle with no signs of infection. MVP with quadrangular resection (P3), annuloplasty and CABG (LITA-LAD, SVG-OM) was performed. The patient was discharged on the 28th postoperative day. Echocardiography showed no MR for four years after the surgery.