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February 19, 2017
Ischemic Cardiomyopathy A Le Piez

A Le Piez.

Etude sur quelques cas de ruptures dites spontanees du coeur. These de Paris, 1873

 

Merat reported the first case of a papillary muscle rupture of the left ventricle in 1803. At autopsy examination, it seemed that the rupture was seconadry to an infectious process. Merat also noted an enlarged heart and an associated aneurysm of the ascending aorta. Three years later, Jean-Nicolas Corvisart, the physician of Napoleon, described a case of papillary musle rupture in his historical monograph. The etiology of papillary muscle rupture was traumatic. In his text, Corvisart referred to the first description of this entity by Merat. In 1824, Bertin also reported a case of papillary muscle rupture involving the right ventricle in a young female patient. Following the postmortem examination, he postulated that the rupture was caused by tuberculosis and the formation of multiple intraventricular vegetations.

In 1873, Le Piez reported in his medical thesis the case of a 74 year-old female who presented with episodes of squeezing chest pain and syncope. The patient died from congestive heart failure. At autopsy examination, Le Piez noted the "softening of the myocardium" reflecting the occurrence of myocardial infarction. He also remarked the presence of  "firm grey clots" in some small and large coronary arteries. This is the first report in which the relation between papillary muscle rupture and coronary artery disease is strongly suggested.

During the first three decades of the 20th century, several case reports of papillary muscle rupture associated with coronary atherosclerosis and often intracoronary thrombus formation were published. Stevenson and Turner reviewed the entire literature on this subject in 1935 and were able to identify twenty cases. In the majority of the cases, the clinical manifestation was dramatic with sudden occurrence of severe chest pain and dyspnea. At physical examination, an apical systolic murmur of varying intensity was commonly present. The evolution of the disease was rapidly progressive with cardiac collapse and death. At postmortem examination, the rupture of the posterior papillary muscle of the left ventricle was most often noted.

In 1948, Davison published a case series which included three patients. In the introduction, he wrote:

"Spontaneous rupture of a papillary muscle is a rarity. Even less common must be the antemortem diagnosis of this condition, for no such instance has been found in the literauture. The opportunity to observe a case of this kind and to establish its correct clinical diagnosis accordingly has prompted this report."

Davison is credited with the first antemortem diagnosis of this condition and remaked in the conclusion of his manuscript:

"...the clinical diagnosis of a ruptured papillary muscle may be considered in a patient with evidence of recent myocardial infarction and with a change in the character and intensity of a murmur which antedated the infarction. The murmur is usually mitral in position, systolic in time, and becomes loud and harsh. Or, in a patient known not to have had any cardiac murmurs, an acute myocardial infarction develops, and some time during the course of the illness a harsh mitral systolic murmur appears. There is usually a sudden radical change in the patient's condition associated with the occurrence of the muscle rupture. Indeed , as has been already stressed, rapid exitus is common. Nevertheless, keeping the above points in mind, and given a situation where sudden death does not occur, the diagnosis may be entertained."

REFERENCES

Merat FB. Observations sur une lesion organique du coeur, par rupture d'une des colonnes charnues du ventricule gauche. J Med Chir Pharm 1803;6:587-600

Corvisart JN. Essai sur les maladies et les lesions organiques du coeur et des gros vaisseaux. Paris, Mequignon- Marvis, 1806

Bertin RJH. Traite des maladies du coeur et des gros vaisseaux. Paris, J.B. Bailliere, 1824

Stevenson RR, Turner WJ. Rupture of a papillary muscle in the heart as a cause of sudden death. Bull Johns Hopkins Hosp 1935; 57:235-242

Davison S. Spontaneous rupture of a papillary muscle of the heart. J Mt Sinai Hosp 1948;14:941-953


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Henri Huchard


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