Article, Cardiology

Papillary muscle rupture associated to essential thrombocytosis

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Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 32 (2014) 1556.e1-1556.e2

Papillary muscle rupture associated to essential thrombocytosis

Abstract

Essential thrombocytosis (ET) falls under the umbrella of myelo- proliferative disorders, which also includes chronic myelogenous leukemia, polycythemia vera, and myelofibrosis with myeloid metaplasia. Essential thrombocytosis results from a clonal prolifera- tion of megakaryocites within the bone marrow, leading to an absolute elevation of platelets that can cause both hemorrhagic and thrombotic complications.

This report details an uncommon presentation of ET with coronary embolism and papillary muscle rupture.

Essential thrombocytosis (ET) falls under the umbrella of myeloprolif- erative disorders, which also includes chronic myelogenous leukemia, polycythemia vera, and myelofibrosis with myeloid metaplasia [1,2]. Essential thrombocytosis results from a clonal proliferation of megakar- yocites within the bone marrow, leading to an absolute elevation of platelets that can cause both hemorrhagic and thrombotic complications [3,4].

This report details an uncommon presentation of ET with coronary embolism and papillary muscle (PM) rupture.

A 74-year-old woman with history of Arterial hypertension and ET presented to the emergency department complaining of a 5-day history of intermittent chest pain and severe dyspnea.

On arrival, she had bilateral pulmonary edema in addition to a III/VI systolic murmur that radiated to the axilla suggesting mitral regurgitation (MR). ECG revealed mild ST-segment elevation in inferior leads. Laboratory results showed platelet count (960.000/mL) and troponin I

1.95 ng/mL (normal, b 0.04 ng/mL).

The patient underwent coronary angiography that showed only a 20% lesion on the midportion in the circumflex coronary artery. echocardiographic evaluation was performed to elucidate the etiology of the pulmonary edema.

In the 2-chamber view posterior, PM rupture is demonstrated. In this case, both PM provide cords to both mitral leaflets. Cusp rupture of the anterior leaflet presents abnormal closure. Color Doppler (4-chamber view) shows mitral MR jet coursing laterally to

the left atrial wall. In the transgastric 90? in diastole shows flail cusp of the posterior PM inside left ventricular are shown (Fig.).

After surgical valve replacement, MRI was performed revealing transmural hyperintensity localized at the level of the mid and apical segments of the inferior wall with partial involvement of the posterior PM, typically from coronary embolism (Figure).

This presentation of ET with coronary embolism and PM rupture is an uncommon presentation.

Gustavo Avegliano, MD Diego Conde, MD? Luciano Battioni, MD Paola Kuschnir, MD Florencia Castro, MD Ricardo Ronderos, MD Department of Cardiology

Instituto Cardiovascular de Buenos Aires

Buenos Aires, Argentina

?Corresponding author. Blanco Encalada 1543

Buenos Aires, 1824, Argentina.

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.04.038

References

  1. Tefferi A, Hoagland HC. Issues in the diagnosis and management of essential thrombocythemia. Mayo Clin Proc 1994;69(7):651-5.
  2. Murphy S, Iland H, Rosenthal D, Laszlo J. essential thrombocythemia: an interim report from the Polycythemia Vera Study Group. Semin Hematol 1986;23 (3):177-82.
  3. Cortelazzo S, Viero P, Finazzi G, D’Emilio A, Rodeghiero F, Barbui T. Incidence and risk factors for thrombotic complications in a historical cohort of 100 patients with essential thrombocythemia. J Clin Oncol 1990;8(3):556-62.
  4. Qanadli SD1, Rangheard AS, Lacombe P. Intraluminal thrombus of the ascending aorta with systemic embolism detected by spiral CT. Clin Radiol 2000;55(1):75-7.

    0735-6757/(C) 2014

    1556.e2 G. Avegliano et al. / American Journal of Emergency Medicine 32 (2014) 1556.e11556.e2

    image of Fig

    Fig. Severe mitral insufficiency secondary to PM rupture in a patient with ET.

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