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Ischemic mitral regurgitation

INTRODUCTION

Ischemic mitral regurgitation (MR) is a complication of coronary heart disease; it primarily occurs in patients with a prior myocardial infarction (MI). MR may also occur with acute ischemia, a setting in which the MR typically resolves after the ischemia resolves. Following an MI, the MR is usually due to infarction with permanent damage to the papillary muscle or adjacent myocardium; in such patients, MR may become more severe with adverse remodeling of the left ventricle or subsequent ischemia. Thus, a better term for this condition might be “post-infarction” MR. (See "Mechanical complications of acute myocardial infarction".)

The optimal treatment of ischemic MR is a matter of controversy and there is wide variation in practice among cardiovascular surgeons. Much of this controversy stems from a lack of good data addressing this issue. There has been one randomized trial comparing mitral valve repair and replacement in this population [1]. Many of the early surgical studies included patients with different types of mitral valve disease, including patients who had degenerative mitral valve disease with prolapse and/or partial flail leaflet in association with coronary heart disease.

Better definitions of ischemic MR have evolved, as echocardiographic techniques have allowed appropriate classification of these patients. This has allowed the performance of higher quality studies, although the lack of randomized trials still limits the ability to make strong recommendations for management.

An overview of the presentation and management of patients with ischemic MR is presented here. The special case of papillary muscle rupture in the setting of acute MI is discussed briefly, but a more extensive review is found separately. (See "Mechanical complications of acute myocardial infarction".)

DEFINITIONS

Most studies of ischemic mitral regurgitation (MR) have focused on chronic post-infarction MR, rather than reversible MR caused by acute ischemia. Ischemic MR can be classified by the mechanism of the valve dysfunction [2,3]:

                        

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Literature review current through: Sep 2014. | This topic last updated: Jul 28, 2014.
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References
Top
  1. 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.
  2. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 2001; 122:1125.
  3. Miller DC. Ischemic mitral regurgitation redux--to repair or to replace? J Thorac Cardiovasc Surg 2001; 122:1059.
  4. Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation 2005; 112:745.
  5. Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of ischemic mitral regurgitation. An experimental evaluation. Circulation 1991; 84:2167.
  6. 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.
  7. 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.
  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. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. Piérard LA, Lancellotti P. The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 2004; 351:1627.
  19. 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.
  20. 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.
  21. Hayakawa M, Inoh T, Kawanishi H, et al. [Two-dimensional echocardiographic findings of patients with papillary muscle dysfunction]. J Cardiogr 1982; 12:137.
  22. Godley RW, Wann LS, Rogers EW, et al. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation 1981; 63:565.
  23. Kwan J, Shiota T, Agler DA, et al. Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation: real-time three-dimensional echocardiography study. Circulation 2003; 107:1135.
  24. 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.
  25. 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.
  26. 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.
  27. 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.
  28. 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.
  29. 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.
  30. 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.
  31. 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.
  32. Aklog L, Filsoufi F, Flores KQ, et al. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation 2001; 104:I68.
  33. 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.
  34. Kishon Y, Oh JK, Schaff HV, et al. Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients. Mayo Clin Proc 1992; 67:1023.
  35. Lavie CJ, Gersh BJ. Mechanical and electrical complications of acute myocardial infarction. Mayo Clin Proc 1990; 65:709.
  36. David TE. Techniques and results of mitral valve repair for ischemic mitral regurgitation. J Card Surg 1994; 9:274.
  37. Edwards FH, Peterson ED, Coombs LP, et al. Prediction of operative mortality after valve replacement surgery. J Am Coll Cardiol 2001; 37:885.
  38. Kang DH, Sun BJ, Kim DH, et al. Percutaneous versus surgical revascularization in patients with ischemic mitral regurgitation. Circulation 2011; 124:S156.
  39. 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.
  40. 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.
  41. 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.
  42. 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.
  43. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
  44. 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.
  45. 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.
  46. 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.
  47. 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.
  48. 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.
  49. 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.
  50. 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.
  51. 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.
  52. Webb JG, Harnek J, Munt BI, et al. Percutaneous transvenous mitral annuloplasty: initial human experience with device implantation in the coronary sinus. Circulation 2006; 113:851.
  53. 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.