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Chordal Rupture – Causes, Symptoms & Treatment
A chordal rupture is the tearing of one or more chordae tendineae in the heart, which support the valve leaflets. It can lead to severe valve regurgitation and heart failure.
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A chordal rupture is the tearing of one or more chordae tendineae in the heart, which support the valve leaflets. It can lead to severe valve regurgitation and heart failure.
What Is a Chordal Rupture?
A chordal rupture refers to the tearing of one or more chordae tendineae – thin, tendon-like cords inside the heart that connect the leaflets of the mitral or tricuspid valve to the papillary muscles of the ventricular wall. These cords prevent the valve leaflets from prolapsing (flipping backwards) during a heartbeat. When a chord ruptures, the affected leaflet loses its support and can no longer close properly, resulting in valvular regurgitation – a backflow of blood in the wrong direction.
Causes
A chordal rupture can result from several underlying conditions:
- Myxomatous valve degeneration: A connective tissue disorder that weakens the chordae, making them prone to rupture. This is the most common cause in adults.
- Infective endocarditis: A bacterial infection of the inner lining of the heart that can destroy the chordae tendineae.
- Rheumatic fever: An inflammatory condition following streptococcal infection that can damage heart structures over time.
- Myocardial infarction (heart attack): Infarction of a papillary muscle can destabilize the chordae and lead to rupture.
- Chest trauma: Blunt thoracic injuries can, in rare cases, cause a chordal rupture.
- Spontaneous rupture: Occurring without a clear cause, often in structurally weakened chordae.
Symptoms
Symptoms vary depending on the number of chordae ruptured and the speed of onset:
- Acute severe shortness of breath (dyspnea), especially when lying flat
- Heart palpitations and irregular heartbeat
- Pulmonary edema: Fluid accumulation in the lungs due to acute valve insufficiency
- Dizziness and weakness
- Newly audible heart murmur detected during auscultation
- In severe cases: cardiogenic shock with life-threatening circulatory failure
Diagnosis
The diagnosis of a chordal rupture is typically established using the following methods:
- Echocardiography (cardiac ultrasound): The primary diagnostic tool. It allows direct visualization of the ruptured chord, the prolapsing leaflet, and the severity of regurgitation. Transesophageal echocardiography (TEE) provides even more detailed imaging.
- ECG (electrocardiogram): To detect cardiac arrhythmias.
- Chest X-ray: To evaluate pulmonary congestion or cardiac enlargement.
- Cardiac catheterization: Used if needed to assess cardiac function and coronary arteries prior to surgery.
Treatment
Emergency Management
An acute chordal rupture with severe valve regurgitation is a medical emergency. Immediate measures include hemodynamic stabilization, treatment of pulmonary edema with medications (e.g., diuretics, vasodilators), and close monitoring in an intensive care unit.
Surgical Treatment
Definitive therapy is usually surgical:
- Valve repair (valvuloplasty): The preferred approach, in which the affected valve is repaired and the ruptured chordae are replaced with artificial Gore-Tex neochords. This procedure offers excellent long-term outcomes.
- Valve replacement: If repair is not feasible, the valve is replaced with a mechanical or biological prosthesis.
Conservative Management
In mild cases or as a bridge to surgery, medications such as ACE inhibitors, beta-blockers, and diuretics can be used to reduce cardiac workload and manage symptoms.
Prognosis
The prognosis following a chordal rupture depends greatly on the severity of the resulting valve regurgitation and the timeliness of treatment. Early surgical intervention, particularly valve repair, leads to significant improvement in cardiac function and quality of life for most patients.
References
- Vahanian A et al. - 2021 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal, 2022.
- Carpentier A - Cardiac valve surgery - the French correction. Journal of Thoracic and Cardiovascular Surgery, 1983.
- Nishimura RA et al. - 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology, 2014.
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