Transcatheter edge-to-edge repair for post-myocardial infarction papillary muscle rupture: a systematic review of patient-level and aggregate outcomes

Papillary muscle rupture (PMR) is a rare mechanical complication of acute myocardial infarction (AMI) that causes acute severe mitral regurgitation (MR), pulmonary edema, and cardiogenic shock. Surgery remains standard therapy, but many patients are prohibitive surgical risk. Transcatheter edge-to-edge repair (TEER) has emerged as a rescue option, although reported outcomes are vulnerable to selection and publication bias. We performed a systematic review in accordance with PRISMA 2020. Eligible reports described TEER for acute severe MR caused by definite papillary muscle rupture or papillary muscle tear attributable to AMI or acute myocardial ischemia. Two reviewers independently screened titles/abstracts and full texts and independently extracted data using a standardized form; disagreements were resolved by consensus, with senior-author adjudication when required. Aggregate series and registry data were analyzed separately to avoid duplicate counting. Thirty-one eligible reports were identified. After accounting for one overlapping companion case report within a later aggregate series, the primary non-overlapping synthesis comprised 55 unique patients: 27 patients from selected individual reports and 28 patients from three consecutive or multicenter series. Among individual reports with available data, cardiogenic shock or other critical illness was documented in 24/24, and temporary circulatory or respiratory support was used in 19/21. Survival to hospital discharge was 27/27 (100%) in selected individual reports versus 19/28 (67.9%) in consecutive/multicenter series. This 32.1-percentage-point difference is consistent with substantial publication and selection bias but may also reflect differences in case mix, anatomy, procedural era, device generation, and center experience. IREMMI registry data showed similar discharge survival in a less-selected population. TEER is technically feasible as a rescue strategy for selected patients with post-AMI PMR when emergency surgery is prohibitive, but the available evidence does not establish comparative efficacy or survival benefit. Outcomes from isolated case reports are substantially more favorable than outcomes from consecutive series. TEER is best framed as emergency stabilization and a bridge to reassessment, with delayed surgery as one possible subsequent pathway. Consecutive multicenter registries and standardized reporting are needed. This review was not prospectively registered (see Methods, Design and registration).