“RFEF” and mitral regurgitation jet direction: surrogate markers for likelihood of left ventricle reverse remodeling in patients with moderate chronic ischemic mitral regurgitation
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Surgical management of moderate chronic ischemic mitral regurgitation (CIMR) is controversial. We propose a simplified classification of moderate CIMR based on regurgitant fraction (RF), ejection fraction (EF), and jet direction (central/eccentric) to predict left ventricle (LV) remodeling and identify patient subsets which need mitral valve (MV) repair along with coronary artery bypass grafting (CABG).
In this prospective controlled study (n = 210), patients with moderate CIMR were randomized. Group I (n = 106) underwent off-pump CABG alone while group II (n = 104) underwent CABG + MV repair. The product of regurgitation fraction and ejection fraction (“RFEF”) was taken as a surrogate for myocardial reserve. The cut-off defined was 0.12; patients with RFEF ≤ 0.12 were categorized as the “bad” and those with RFEF > 0.12 as the “good” subset. The patients were further subdivided on the basis of their mitral regurgitation (MR) jet direction (central/eccentric). The percentage improvement in left ventricular end-systolic volume index (LVESVI) and MR grade were recorded 6 monthly.
Analysis of the continuous variable “RFEF” in conjunction with jet direction was performed. At 12 months, the patient in good subset with central direction of jet showed improvement in LVESVI % in both groups (p = 0.428), while the patients in bad subset with eccentric direction of jet showed significantly higher improvement in LVESVI %, group II as compared to group I (p = 0.004).
This study thus identifies “RFEF” as a surrogate for reverse remodeling capacity. In association with MR jet direction, predicts the subset of moderate CIMR patients most likely to have maximum LVESVI and MR grade reduction.
KeywordsIschemic mitral regurgitation Coronary artery disease Heart failure
This work was supported by U.N. Mehta Institute of Cardiology and Research Center itself and received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
The study does not involve the use of any animal. And in case of patients, all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent has been taken from patients and none have been forced to be a part of the study.
- 2.Puskas JD, Williams WH, Duke PG, et al. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:797–808.CrossRefGoogle Scholar
- 3.Spartera M, Galderisi M, Mele D, et al. Role of cardiac dyssynchrony and resynchronization therapy in functional mitral regurgitation. EurHeart J Cardiovasc Imaging. 2016;17:471–80.Google Scholar
- 5.Carpentier A. Cardiac valve surgery-the “French correction”. J Thorac Cardiovasc Surg. 1983;86:323–37.Google Scholar
- 6.Nishimura RA, Otto CM, Bonow RO, et al. AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:2440–92.Google Scholar
- 14.Ueno T, Sakata R, Iguro Y, et al. Left ventricular reconstruction with or without mitral annuloplasty. Ann Thorac Cardiovasc Surg. 2009;15:165–70.Google Scholar
- 18.Ryden T, Bech-Hanssen O, Brandrup-Wognesen G, Nilsson F, Svensson S, Jeppsson A. The importance of grade 2 ischemic mitral regurgitation in coronary artery bypass grafting. Eur J Cardiothorac Surg. 2001;20:276–81.Google Scholar
- 19.Lindeboom JE, Jaarsma W, Kelder JC, Morshuis WJ, Visser CA. Mitral valve repair is not always needed in patients with functional mitral regurgitation undergoing coronary artery bypass grafting and/or aortic valve replacement. Neth Heart J. 2005;13:175–80.Google Scholar
- 20.Bax JJ, Braun J, Somer ST, et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation 2004; 110: II-103–II-108.Google Scholar
- 24.Michler RE, Smith PK, Parides MK, et al. Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med. 2016;374:1932–41.Google Scholar
- 25.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;126:2502–10.Google Scholar
- 27.Dion R. Ischemic mitral regurgitation: when and how should it be corrected? J Heart Valve Dis. 1993;5:536–43.Google Scholar
- 30.Yu HY, Su MY, Liao TY, Peng HH, Lin FY, Tseng WY. Functional mitral regurgitation in chronic ischemic coronary artery disease: analysis of geometric alterations of mitral apparatus with magnetic resonance imaging. J Thorac Cardiovasc Surg. 2004;128:543–51.Google Scholar
- 31.Beeri R, Yosefy C, Guerrero JL, et al. Early repair of moderate ischemic mitral regurgitation reverses left ventricular remodeling a functional and molecular study. Circulation 2007; 116]:I-288–I-293.Google Scholar
- 34.Kumanohoso T, Otsuji Y, Yoshifuku S, et al. Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. J Thorac Cardiovasc Surg. 2003;125:135–43.CrossRefGoogle Scholar