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Ischemic mitral regurgitation

Author
William H Gaasch, MD
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Ischemic mitral regurgitation (MR) is a complication of coronary heart disease, and its broad definition includes a spectrum of disorders including chronic MR post myocardial infarction (MI), acute MR (or acute worsening of MR) with acute MI (ST elevation or non-ST elevation), and reversible MR due to myocardial ischemia.

An overview of the presentation and management of patients with ischemic MR is presented here, with most of the discussion focused on chronic functional ischemic MR. Acute MR in the setting of acute MI including MR caused by papillary muscle rupture is discussed separately. (See "Mechanical complications of acute myocardial infarction" and "Acute mitral regurgitation in adults".)

DEFINITIONS

Most studies of ischemic mitral regurgitation (MR) have focused on chronic post-infarction MR rather than acute MR in the setting of acute myocardial infarction (MI) or reversible MR caused by acute ischemia. Thus, the term "ischemic MR" is used by primarily to indicate chronic functional post-infarction MR.

MR caused by coronary artery disease can be classified by the mechanism of the valve dysfunction [1,2]:

The vast majority of patients with ischemic MR have "functional" or "secondary" MR post MI. Thus, a better term for this condition might be "post-infarction" MR. Focal and/or global left ventricular systolic dysfunction and adverse left ventricular remodeling causes restricted leaflet motion and failure of leaflet coaptation [3].

                           

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Literature review current through: Jul 2015. | This topic last updated: Mar 23, 2015.
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References
Top
  1. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 2001; 122:1125.
  2. Miller DC. Ischemic mitral regurgitation redux--to repair or to replace? J Thorac Cardiovasc Surg 2001; 122:1059.
  3. Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation 2005; 112:745.
  4. Heuser RR, Maddoux GL, Goss JE, et al. Coronary angioplasty for acute mitral regurgitation due to myocardial infarction. A nonsurgical treatment preserving mitral valve integrity. Ann Intern Med 1987; 107:852.
  5. Shawl FA, Forman MB, Punja S, Goldbaum TS. Emergent coronary angioplasty in the treatment of acute ischemic mitral regurgitation: long-term results in five cases. J Am Coll Cardiol 1989; 14:986.
  6. Weinstein JM, Kidman G, Ilia R. Collateral-dependent ischemic mitral regurgitation. J Invasive Cardiol 2014; 26:E27.
  7. Uemura T, Otsuji Y, Nakashiki K, et al. Papillary muscle dysfunction attenuates ischemic mitral regurgitation in patients with localized basal inferior left ventricular remodeling: insights from tissue Doppler strain imaging. J Am Coll Cardiol 2005; 46:113.
  8. Yiu SF, Enriquez-Sarano M, Tribouilloy C, et al. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation 2000; 102:1400.
  9. Izumi S, Miyatake K, Beppu S, et al. Mechanism of mitral regurgitation in patients with myocardial infarction: a study using real-time two-dimensional Doppler flow imaging and echocardiography. Circulation 1987; 76:777.
  10. Magne J, Pibarot P. Left ventricular systolic function in ischemic mitral regurgitation: time to look beyond ejection fraction. J Am Soc Echocardiogr 2013; 26:1130.
  11. Chaput M, Handschumacher MD, Tournoux F, et al. Mitral leaflet adaptation to ventricular remodeling: occurrence and adequacy in patients with functional mitral regurgitation. Circulation 2008; 118:845.
  12. Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of ischemic mitral regurgitation. An experimental evaluation. Circulation 1991; 84:2167.
  13. Hung J, Guerrero JL, Handschumacher MD, et al. Reverse ventricular remodeling reduces ischemic mitral regurgitation: echo-guided device application in the beating heart. Circulation 2002; 106:2594.
  14. Tenenbaum A, Leor J, Motro M, et al. Improved posterobasal segment function after thrombolysis is associated with decreased incidence of significant mitral regurgitation in a first inferior myocardial infarction. J Am Coll Cardiol 1995; 25:1558.
  15. Tcheng JE, Jackman JD Jr, Nelson CL, et al. Outcome of patients sustaining acute ischemic mitral regurgitation during myocardial infarction. Ann Intern Med 1992; 117:18.
  16. Lehmann KG, Francis CK, Dodge HT. Mitral regurgitation in early myocardial infarction. Incidence, clinical detection, and prognostic implications. TIMI Study Group. Ann Intern Med 1992; 117:10.
  17. Barzilai B, Davis VG, Stone PH, Jaffe AS. Prognostic significance of mitral regurgitation in acute myocardial infarction. The MILIS Study Group. Am J Cardiol 1990; 65:1169.
  18. Pellizzon GG, Grines CL, Cox DA, et al. Importance of mitral regurgitation inpatients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. J Am Coll Cardiol 2004; 43:1368.
  19. Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation 2005; 111:295.
  20. Perez de Isla L, Zamorano J, Quezada M, et al. Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome. Eur Heart J 2006; 27:2655.
  21. Aronson D, Goldsher N, Zukermann R, et al. Ischemic mitral regurgitation and risk of heart failure after myocardial infarction. Arch Intern Med 2006; 166:2362.
  22. Piérard LA, Lancellotti P. The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 2004; 351:1627.
  23. Hayakawa M, Inoh T, Kawanishi H, et al. [Two-dimensional echocardiographic findings of patients with papillary muscle dysfunction]. J Cardiogr 1982; 12:137.
  24. Godley RW, Wann LS, Rogers EW, et al. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation 1981; 63:565.
  25. Lancellotti P, Lebrun F, Piérard LA. Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol 2003; 42:1921.
  26. Lancellotti P, Troisfontaines P, Toussaint AC, Pierard LA. Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction. Circulation 2003; 108:1713.
  27. Shiran A, Merdler A, Ismir E, et al. Intraoperative transesophageal echocardiography using a quantitative dynamic loading test for the evaluation of ischemic mitral regurgitation. J Am Soc Echocardiogr 2007; 20:690.
  28. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
  29. Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 2001; 103:1759.
  30. Lamas GA, Mitchell GF, Flaker GC, et al. Clinical significance of mitral regurgitation after acute myocardial infarction. Survival and Ventricular Enlargement Investigators. Circulation 1997; 96:827.
  31. Tischler MD, Cooper KA, Rowen M, LeWinter MM. Mitral valve replacement versus mitral valve repair. A Doppler and quantitative stress echocardiographic study. Circulation 1994; 89:132.
  32. Feinberg MS, Schwammenthal E, Shlizerman L, et al. Prognostic significance of mild mitral regurgitation by color Doppler echocardiography in acute myocardial infarction. Am J Cardiol 2000; 86:903.
  33. Grossi EA, Goldberg JD, LaPietra A, et al. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg 2001; 122:1107.
  34. Grigioni F, Detaint D, Avierinos JF, et al. Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction. J Am Coll Cardiol 2005; 45:260.
  35. Diodato MD, Moon MR, Pasque MK, et al. Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis. Ann Thorac Surg 2004; 78:794.
  36. Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med 2014; 370:23.
  37. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  38. van Bommel RJ, Marsan NA, Delgado V, et al. Cardiac resynchronization therapy as a therapeutic option in patients with moderate-severe functional mitral regurgitation and high operative risk. Circulation 2011; 124:912.
  39. Leor J, Feinberg MS, Vered Z, et al. Effect of thrombolytic therapy on the evolution of significant mitral regurgitation in patients with a first inferior myocardial infarction. J Am Coll Cardiol 1993; 21:1661.
  40. Chua S, Hung J, Chung SY, et al. Primary percutaneous coronary intervention lowers the incidence of ischemic mitral regurgitation in patients with acute ST-elevated myocardial infarction. Circ J 2010; 74:2386.
  41. Poh KK, Lee GK, Lee LC, et al. Reperfusion therapies reduce ischemic mitral regurgitation following inferoposterior ST-segment elevation myocardial infarction. Coron Artery Dis 2012; 23:555.
  42. Aklog L, Filsoufi F, Flores KQ, et al. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation 2001; 104:I68.
  43. Penicka M, Linkova H, Lang O, et al. Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery. Circulation 2009; 120:1474.
  44. Wong DR, Agnihotri AK, Hung JW, et al. Long-term survival after surgical revascularization for moderate ischemic mitral regurgitation. Ann Thorac Surg 2005; 80:570.
  45. Mihaljevic T, Lam BK, Rajeswaran J, et al. Impact of mitral valve annuloplasty combined with revascularization in patients with functional ischemic mitral regurgitation. J Am Coll Cardiol 2007; 49:2191.
  46. Smith PK, Puskas JD, Ascheim DD, et al. Surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med 2014; 371:2178.
  47. Kang DH, Sun BJ, Kim DH, et al. Percutaneous versus surgical revascularization in patients with ischemic mitral regurgitation. Circulation 2011; 124:S156.
  48. Fattouch K, Guccione F, Sampognaro R, et al. POINT: Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. J Thorac Cardiovasc Surg 2009; 138:278.
  49. Chan KM, Punjabi PP, Flather M, et al. Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the Randomized Ischemic Mitral Evaluation (RIME) trial. Circulation 2012; 126:2502.
  50. Vassileva CM, Boley T, Markwell S, Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation. Eur J Cardiothorac Surg 2011; 39:295.
  51. Rao C, Murphy MO, Saso S, et al. Mitral valve repair or replacement for ischaemic mitral regurgitation: a systematic review. Heart Lung Circ 2011; 20:555.
  52. McGee EC, Gillinov AM, Blackstone EH, et al. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2004; 128:916.
  53. Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 2004; 110:II85.
  54. Kongsaerepong V, Shiota M, Gillinov AM, et al. Echocardiographic predictors of successful versus unsuccessful mitral valve repair in ischemic mitral regurgitation. Am J Cardiol 2006; 98:504.
  55. Di Mauro M, Calafiore AM, Penco M, et al. Mitral valve repair for dilated cardiomyopathy: predictive role of right ventricular dysfunction. Eur Heart J 2007; 28:2510.
  56. Borger MA, Murphy PM, Alam A, et al. Initial results of the chordal-cutting operation for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2007; 133:1483.
  57. de Varennes B, Chaturvedi R, Sidhu S, et al. Initial results of posterior leaflet extension for severe type IIIb ischemic mitral regurgitation. Circulation 2009; 119:2837.
  58. Hausmann H, Siniawski H, Hetzer R. Mitral valve reconstruction and replacement for ischemic mitral insufficiency: seven years' follow up. J Heart Valve Dis 1999; 8:536.