Ischemic Mitral Regurgitation: In Search of the Best Treatment for a Common Condition☆

https://doi.org/10.1016/j.pcad.2008.08.006Get rights and content

Ischemic mitral regurgitation (IMR) is common after myocardial infarction. It results in a significantly increased risk of congestive heart failure and death. The assessment of these patients is challenging as IMR is a dynamic condition and varies in severity under different physiologic conditions, such as physical exertion and changes in left ventricle (LV) contractility. Assessment, therefore, includes both the mitral valve and the LV and needs to be done at rest and under conditions of stress. Treatment of IMR involves optimization of medical therapy for coronary artery disease, coronary artery revascularization, and mitral valve surgery. Most patients have mild IMR and undergo isolated coronary artery revascularization either by percutaneous coronary intervention or coronary artery bypass graft surgery (CABG). In those with severe IMR, mitral valve repair or replacement is indicated, especially if the patient is symptomatic or has impaired LV function or LV dilatation. The optimal treatment of moderate IMR is controversial; mitral valve repair at the time of CABG may be beneficial, but randomized controlled trials are needed. In selected patients with papillary muscle dyssynchrony, cardiac resynchronization therapy may also be helpful.

Section snippets

Pathophysiology of IMR

The mitral valve apparatus consists of the leaflets, annulus, chordae, and papillary muscles (Fig. 1). It is attached to the LV at the annulus and the papillary muscles. Pathologic condition in any of the components of the mitral valve or the LV can lead to mitral regurgitation. In most cases of IMR, the mitral valve is normal in structure; mitral regurgitation occurs secondary to LV dysfunction and dilatation. In a minority of cases, IMR occurs due to rupture of the papillary muscles.5

Assessment of IMR

Assessment of IMR involves the mitral valve anatomy and function, the severity of IMR, the LV function and viability, and the severity of coronary disease.

Treatment Options

Patients with IMR are treated for their coronary artery disease with optimization of medical therapy and coronary artery revascularization. In addition, mitral valve surgery is indicated in those with severe IMR.16 Most patients, however, have mild or moderate IMR, and it is uncertain if mitral valve intervention improves outcome in these patients.1, 2 It has been suggested that, if these patients are undergoing coronary artery bypass graft surgery (CABG), then mitral valve repair should be

Conclusion

Ischemic mitral regurgitation is common after myocardial infarction. It carries an adverse prognosis with an increased risk of severe heart failure and death and should be assessed in patients after myocardial infarction. Its assessment is challenging as it is a dynamic condition and its severity varies with physical exertion and LV contractility. Assessment should, therefore, be done both at rest and stress, and must include assessment of LV function and viability.

The treatment of IMR involves

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      Lamas et al [33] demonstrated that IMR after MI, often clinically unrecognised, is associated with a significant increase in subsequent cardiac death. There were several studies designed to assess the effect of CABG alone and adding MVR to CABG in patients with IMR, major results of these findings favour the combined CABG and MVR procedures based on decreased in-hospital mortality and better short- and long-term follow-up [6,15,34–37]. However, Tolis et al [2] and several other studies demonstrate that isolated CABG (without MVR) suffices, producing dramatic improvement in LVEF and in degree of MR. Therefore, substantial heterogeneity among published studies exists, and the confidence limits remain open.

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    ☆

    Supported in part by a Researcher Development Award from the National Institute of Health Research, Department of Health, United Kingdom (RDA/02/06/014), and grants from the British Heart Foundation.

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