Ischemic mitral regurgitation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editors-In-Chief: Varun Kumar, M.B.B.S ; Lakshmi Gopalakrishnan, M.B.B.S

Overview

Ischemic mitral regurgitation can be defined as mitral regurgitation that occurs as a consequence of myocardial infarction or acute myocardial ischemia with resultant alteration in left ventricular geometry or function. Echocardiography should demonstrate that annular dilation or restriction of leaflet motion in systole (Carpentier type IIIb[1]) is the cause of regurgitation[2].

If mitral regurgitation occurs as a complication of MI it is permanent while if it occurs as a result of ischemia, it is transient and resolves with resolution of ischemia.

Pathophysiology

Papillary muscle normally exert a perpendicular force on mitral valve leaflets thereby achieving optimal coaptation. With distortion of left ventricular geometry and displacement of papillary muscle secondary to myocardial ischemia/infarction, the tethering forces are exerted at an oblique angle resulting in insufficient coaptation there by causing regurgitation of blood through mitral valve.

Ischemic Mitral Regurgitation can be due to :

  1. Papillary muscle rupture secondary to acute myocardial infarction.
  2. Dilatation of mitral annulus secondary to left ventricular dysfunction/enlargement causes incomplete mitral valve coaptation with normal leaflet motion[3] [4].
  3. Most often Ischemic Mitral Regurgitation is functional and due to papillary muscle displacement involving a left ventricular-wall motion abnormality as well as alteration in left ventricular geometry [5]. In absence of global left ventricular dysfunction and dilatation, mitral regurgitation resulting from localized left ventricular remodelling with wall motion abnormalities usually occur secondary to myocardial infarction in inferobasal and mid ventricular regions of heart[6]. This can cause displacement of papillary muscles causing suboptimal coaptation of leaflets. A recent study demonstrated that alteration in ventricular geometry secondary to myocardial infarction in anterioapical region with inferoapical extension can also cause significant mitral regurgitation despite normal ventricular contraction in basal inferior and mid ventricular region[7]. This correlates with increased tethering length from the papillary muscle tip to the annulus, and reduced systolic tethering length because of papillary muscle retraction toward the apex.

Epidemiology

A study which evaluated 482 patients with ischemic mitral regurgitation concluded that 76 percent had mitral regurgitation was functional rather than structural [8].

In another community based study[9], 773 patients with STEMI or NSTEMI were evaluated within 30 days of the event using echocardiography and it was found that mitral regurgitation was present in 50% with mild regurgitation in 38% and moderate or severe in 12%

A higher incidence is observed in elderly and women [10] [9] and is associated with anterior wall infarction, persistently occluded infarct artery, larger end-systolic and end-diastolic ventricular volumes, and severe heart failure.

Diagnosis

Symptoms

The clinical presentation of Ischemic mitral regurgitation reflects the state of LV dysfunction more than the state of mitral valve.

  • Asymptomatic detected by Echocardiography or Angiography
  • Weakness, fatigue
  • Exercise Intolerance

Signs

Exercise Echocardiography

  • Effective regurgitant orifice (ERO) area increase with exercise is associated with increased risk for acute pulmonary edema
  • Exercise induced ERO ≥13 mm2 is an independent predictor of cardiac death.
  • 3D ECHO can be helpful in differentiating ischemic mitral regurgitation from functional MR secondary to ventricular dilatation. The valvular abnormality is asymmetric in ischemic mitral regurgitation and symmetric in functional MR.

{{#ev:youtube|ue2oCXo6Qik}} DOPPLER ECHOCARDIOGRAPHY

  • Echocardiogram showing incomplete closure of posterior mitral leaflet due to tethering from MI

Treatment

Treatment varies depending on the severity of ischemic mitral regurgitation with reperfusion in acute MI or heart transplantation.

  • Ischemic mitral regurgitation with normal mitral leaflets but abnormal left ventricular function and geometry can be treated by percutaneous revascularization which decreases ventricular remodeling & hence prevents MR[11] [12] [13].
  • Surgical approach for ischemic mitral regurgitation : The decision for valve surgery should be made prior to CABG as it increases the likelihood of air embolism, prolongs cardiopulmonary bypass time and thereby increasing operative mortality [19].
    • Standard Surgical ring annuloplasty
    • Restrictive annuloplasty
    • Edge-to-edge leaflet repair
    • Chordal manipulation eliminates tethering and restores normal leaflet coaptation [20] [21] [22].
    • Modifying papillary muscle geometry
    • Segmental ventricular constraints
    • Biventricular pacing decreases tardiness of the posterior papillary muscle bearing segment & hence reduces tethering.

In ring annuloplasty antero-posterior annular dimension is reduced to restore coaptation. However, if the annular size alone is reduced, it persistently leaves the tethering to the displaced left ventricular wall and thereby causing recurrent MR[23].

Currently for ischemic mitral valve repair double orifice technique (edge-to-edge repair) along with ring annuloplasty is used to facilitate leaflet coaptation [24].

There is a mixed opinion regarding the outcome of mitral valve repair versus mitral valve replacement in patients with ischemic mitral valve with some investigators reporting mitral valve repair to be associated with better outcome [25] [26] [8].

Transvenous catheter-delivered annuloplasty device is an investigational alternative [27].


Posterior suture annuloplasty for Ischemic mitral regurgitation : {{#ev:youtube|vWUos-0WM5w}}


Prognosis

Ischemic mitral regurgitation is associated with a poor prognosis, however there is no sufficient evidence that the regurgitation is the cause for the poor outcomes and surgical correction of regurgitation at the time of CABG, has little impact on survival with limitation in functional class[14].

Acute ischemic mitral regurgitation is often associated with anterior wall infarction and wall motion abnormality leading to increased left ventricular volumes and subsequent heart failure [28] [9].

Ischemic mitral regurgitation in patients with non-ST elevation acute coronary syndrome, mitral regurgitation was found to be the independent predictor of long term outcome and the presence and degree of mitral regurgitation confer a worse long-term prognosis to patients after the first event. Thus, the assessment of presence of mitral regurgitation in every patient after a non-ST elevation acute coronary syndrome is warranted[29].

Independent of left ventricular function, MR is associated with higher mortality [30].

References

  1. ↑ Carpentier A (1983). "Cardiac valve surgery--the "French correction"". The Journal of Thoracic and Cardiovascular Surgery. 86 (3): 323–37. PMID 6887954. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  2. ↑ Anyanwu AC, Adams DH (2008). "Ischemic mitral regurgitation: recent advances". Current Treatment Options in Cardiovascular Medicine. 10 (6): 529–37. PMID 19026183. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  3. ↑ Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA (1991). "Mechanism of ischemic mitral regurgitation. An experimental evaluation". Circulation. 84 (5): 2167–80. PMID 1934385. Retrieved 2011-04-12. Unknown parameter |month= ignored (help)
  4. ↑ Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik AJ (2000). "Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study". Circulation. 102 (12): 1400–6. PMID 10993859. Retrieved 2011-04-12. Unknown parameter |month= ignored (help)
  5. ↑ Tenenbaum A, Leor J, Motro M, Hod H, Kaplinsky E, Rabinowitz B, Boyko V, Vered Z (1995). "Improved posterobasal segment function after thrombolysis is associated with decreased incidence of significant mitral regurgitation in a first inferior myocardial infarction". Journal of the American College of Cardiology. 25 (7): 1558–63. PMID 7759707. Retrieved 2011-02-20. Unknown parameter |month= ignored (help)
  6. ↑ Uemura T, Otsuji Y, Nakashiki K, Yoshifuku S, Maki Y, Yu B, Mizukami N, Kuwahara E, Hamasaki S, Biro S, Kisanuki A, Minagoe S, Levine RA, Tei C (2005). "Papillary muscle dysfunction attenuates ischemic mitral regurgitation in patients with localized basal inferior left ventricular remodeling: insights from tissue Doppler strain imaging". Journal of the American College of Cardiology. 46 (1): 113–9. doi:10.1016/j.jacc.2005.03.049. PMID 15992644. Retrieved 2011-04-12. Unknown parameter |month= ignored (help)
  7. ↑ Yosefy C, Beeri R, Guerrero JL, Vaturi M, Scherrer-Crosbie M, Handschumacher MD, Levine RA (2011). "Mitral Regurgitation After Anteroapical Myocardial Infarction: New Mechanistic Insights". Circulation. doi:10.1161/CIRCULATIONAHA.110.977843. PMID 21444880. Retrieved 2011-04-12. Unknown parameter |month= ignored (help)
  8. ↑ 8.0 8.1 Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J, Lytle BW, McCarthy PM (2001). "Is repair preferable to replacement for ischemic mitral regurgitation?". The Journal of Thoracic and Cardiovascular Surgery. 122 (6): 1125–41. doi:10.1067/mtc.2001.116557. PMID 11726887. Retrieved 2011-04-12. Unknown parameter |month= ignored (help)
  9. ↑ 9.0 9.1 9.2 Bursi F, Enriquez-Sarano M, Nkomo VT, Jacobsen SJ, Weston SA, Meverden RA, Roger VL (2005). "Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation". Circulation. 111 (3): 295–301. doi:10.1161/01.CIR.0000151097.30779.04. PMID 15655133. Retrieved 2011-04-12. Unknown parameter |month= ignored (help)
  10. ↑ Pellizzon GG, Grines CL, Cox DA, Stuckey T, Tcheng JE, Garcia E, Guagliumi G, Turco M, Lansky AJ, Griffin JJ, Cohen DJ, Aymong E, Mehran R, O'Neill WW, Stone GW (2004). "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". Journal of the American College of Cardiology. 43 (8): 1368–74. doi:10.1016/j.jacc.2003.11.046. PMID 15093869. Retrieved 2011-02-20. Unknown parameter |month= ignored (help)
  11. ↑ Duarte IG, Shen Y, MacDonald MJ, Jones EL, Craver JM, Guyton RA (1999). "Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results". The Annals of Thoracic Surgery. 68 (2): 426–30. PMID 10475407. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  12. ↑ Tolis GA, Korkolis DP, Kopf GS, Elefteriades JA (2002). "Revascularization alone (without mitral valve repair) suffices in patients with advanced ischemic cardiomyopathy and mild-to-moderate mitral regurgitation". The Annals of Thoracic Surgery. 74 (5): 1476–80, discussion 1480–1. PMID 12440595. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  13. ↑ Gorman RC, Gorman JH (2006). "Why should we repair ischemic mitral regurgitation?". The Annals of Thoracic Surgery. 81 (2): 785, author reply 785–6. doi:10.1016/j.athoracsur.2005.07.028. PMID 16427907. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  14. ↑ 14.0 14.1 Diodato MD, Moon MR, Pasque MK, Barner HB, Moazami N, Lawton JS, Bailey MS, Guthrie TJ, Meyers BF, Damiano RJ (2004). "Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis". The Annals of Thoracic Surgery. 78 (3): 794–9, discussion 794–9. doi:10.1016/j.athoracsur.2004.03.022. PMID 15336993. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  15. ↑ Penicka M, Linkova H, Lang O, Fojt R, Kocka V, Vanderheyden M, Bartunek J (2009). "Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery". Circulation. 120 (15): 1474–81. doi:10.1161/CIRCULATIONAHA.108.842104. PMID 19786637. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  16. ↑ Kishon Y, Oh JK, Schaff HV, Mullany CJ, Tajik AJ, Gersh BJ (1992). "Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients". Mayo Clinic Proceedings. Mayo Clinic. 67 (11): 1023–30. PMID 1434862. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  17. ↑ Lavie CJ, Gersh BJ (1990). "Mechanical and electrical complications of acute myocardial infarction". Mayo Clinic Proceedings. Mayo Clinic. 65 (5): 709–30. PMID 2190052. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  18. ↑ David TE (1994). "Techniques and results of mitral valve repair for ischemic mitral regurgitation". Journal of Cardiac Surgery. 9 (2 Suppl): 274–7. PMID 8186580. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  19. ↑ Edwards FH, Peterson ED, Coombs LP, DeLong ER, Jamieson WR, Shroyer ALW, Grover FL (2001). "Prediction of operative mortality after valve replacement surgery". Journal of the American College of Cardiology. 37 (3): 885–92. PMID 11693766. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  20. ↑ Levine RA, Schwammenthal E (2005). "Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts". Circulation. 112 (5): 745–58. doi:10.1161/CIRCULATIONAHA.104.486720. PMID 16061756. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  21. ↑ Borger MA, Murphy PM, Alam A, Fazel S, Maganti M, Armstrong S, Rao V, David TE (2007). "Initial results of the chordal-cutting operation for ischemic mitral regurgitation". The Journal of Thoracic and Cardiovascular Surgery. 133 (6): 1483–92. doi:10.1016/j.jtcvs.2007.01.064. PMID 17532944. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  22. ↑ de Varennes B, Chaturvedi R, Sidhu S, Côté AV, Shan WL, Goyer C, Hatzakorzian R, Buithieu J, Sniderman A (2009). "Initial results of posterior leaflet extension for severe type IIIb ischemic mitral regurgitation". Circulation. 119 (21): 2837–43. doi:10.1161/CIRCULATIONAHA.108.831412. PMID 19451349. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  23. ↑ Hung J, Papakostas L, Tahta SA, Hardy BG, Bollen BA, Duran CM, Levine RA (2004). "Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target". Circulation. 110 (11 Suppl 1): II85–90. doi:10.1161/01.CIR.0000138192.65015.45. PMID 15364844. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  24. ↑ Nielsen SL, Timek TA, Lai DT, Daughters GT, Liang D, Hasenkam JM, Ingels NB, Miller DC (2001). "Edge-to-edge mitral repair: tension on the approximating suture and leaflet deformation during acute ischemic mitral regurgitation in the ovine heart". Circulation. 104 (12 Suppl 1): I29–35. PMID 11568026. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  25. ↑ Oury JH, Cleveland JC, Duran CG, Angell WW (1994). "Ischemic mitral valve disease: classification and systemic approach to management". Journal of Cardiac Surgery. 9 (2 Suppl): 262–73. PMID 8186579. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  26. ↑ Rankin JS, Feneley MP, Hickey MS, Muhlbaier LH, Wechsler AS, Floyd RD, Reves JG, Skelton TN, Califf RM, Lowe JE (1988). "A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation". The Journal of Thoracic and Cardiovascular Surgery. 95 (2): 165–77. PMID 3276968. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  27. ↑ Webb JG, Harnek J, Munt BI, Kimblad PO, Chandavimol M, Thompson CR, Mayo JR, Solem JO (2006). "Percutaneous transvenous mitral annuloplasty: initial human experience with device implantation in the coronary sinus". Circulation. 113 (6): 851–5. doi:10.1161/CIRCULATIONAHA.105.591602. PMID 16461812. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  28. ↑ Aronson D, Goldsher N, Zukermann R, Kapeliovich M, Lessick J, Mutlak D, Dabbah S, Markiewicz W, Beyar R, Hammerman H, Reisner S, Agmon Y (2006). "Ischemic mitral regurgitation and risk of heart failure after myocardial infarction". Archives of Internal Medicine. 166 (21): 2362–8. doi:10.1001/archinte.166.21.2362. PMID 17130390. Retrieved 2011-02-21. Unknown parameter |month= ignored (help)
  29. ↑ Perez de Isla L, Zamorano J, Quezada M, Almería C, Rodrigo JL, Serra V, García Rubira JC, Ortiz AF, Macaya C (2006). "Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome". European Heart Journal. 27 (22): 2655–60. doi:10.1093/eurheartj/ehl287. PMID 17015403. Retrieved 2011-04-12. Unknown parameter |month= ignored (help)
  30. ↑ Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ (2001). "Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment". Circulation. 103 (13): 1759–64. PMID 11282907. Retrieved 2011-02-20. Unknown parameter |month= ignored (help)

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