Ischemic Mitral Regurgitation: A Complex Multifaceted Disease

Abstract

Ischemic mitral regurgitation (MR) is a complex multifactorial disease that involves global and regional left ventricular remodeling as well as dysfunction and distortion of the components of the mitral valve including the chordae, annulus and leaflets. This is a frequent (13–59%) complication of myocardial infarction, which is associated with a poor prognosis. The suboptimal results obtained with the most commonly used surgical strategy, that is, restrictive annuloplasty combined with coronary artery bypass graft, emphasize the need to develop alternative or concomitant surgical techniques that directly target the causal mechanisms of the disease. A comprehensive assessment of mitral valve configuration and left ventricular geometry and function prior to surgery as well as an accurate quantification of MR severity at rest and during exercise may help improve patient risk stratification and better individualize the surgical strategy based on the patient’s specific characteristics. The purpose of this review is to summarize the current state of knowledge with regard to the definition, prevalence, mechanisms, outcome and treatment of ischemic MR.

Surgical treatment of coronary artery disease complicated by mitral insufficiency

“…Moreover, there is only additional unreasonable surgical risk [13,20]. Several studies have shown that one third of patients has recurrnet mitral insufficiency after mitral valve repair up to preoperative level within 3-5 years after surgery [14,23]. The concept of isolated coronary intervention is based on several important arguments.…”

“…Ряд авторов [13,20] придерживаются мне-ния, что коррекция МН не останавливает прогрессирова-ния ремоделирования ЛЖ и не влияет на выживаемость пациентов, а лишь добавляет необоснованный риск при хирургическом вмешательстве. Несколько исследований [14,23] показали, что у 1 / 3 пациентов после пластики МК наблюдается возврат МН на предоперационный уровень в течение 3-5 лет после операции. Концепция изолированного вмешательства на КА ба-зируется на нескольких весомых аргументах.…”

Mitral valve repair and subvalvular intervention for secondary mitral regurgitation: a systematic review and meta-analysis of randomized controlled and propensity matched studies

“…Secondary mitral regurgitation (MR) develops in up to one-half of patients with an ischemic or non-ischemic dilated cardiomyopathy (1,2). The primary substrate for secondary MR is adverse left ventricular (LV) remodeling and dilatation, which distorts the mitral valve (MV) apparatus geometry.…”

“…This results in posterolateral and apical displacement of the papillary muscles, an impaired systolic shortening of the interpapillary muscle distance, tethering and restricted systolic closure of the MV leaflets, and subsequently, the development of secondary MR (3)(4)(5). Despite guideline-directed medical therapy, revascularization of significant coronary artery disease, and cardiac resynchronization therapy when indicated, secondary MR often persists and is associated with significant morbidity and mortality proportional to its severity (1,2,6).…”

Staged percutaneous coronary intervention followed by minimally invasive mitral valve surgery versus combined coronary artery bypass graft and mitral valve surgery for two-vessel coronary artery disease and moderate to severe ischemic mitral regurgitation

“…Moderate to severe ischemic mitral regurgitation (IMR) develops in 35% of patients after a myocardial infarction, and is associated with a 2-fold increase in mortality (1,2). While myocardial revascularization may improve IMR, there is a 40% incidence of persistent or worsening IMR at follow-up (3).…”