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Ischemic mitral regurgitation: current understanding and surgical options

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Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Secondary, or functional, mitral regurgitation (MR) occurs with impaired coaptation of structurally normal valve leaflets due to abnormal structure and/or function of the left ventricle (LV). A leading cause of functional mitral regurgitation is ischemic cardiomyopathy, resulting in left ventricular dysfunction and subsequent congestive heart failure (CHF) and ischemic mitral regurgitation (IMR). The value of surgical or transcatheter correction of IMR remains controversial, since the underlying pathology of IMR is attributed to a dysfunctional left ventricle. However, even mild IMR has been shown to be harmful to CHF patients, as IMR is both a surrogate of advanced CHF and an independent contributor to CHF morbidity and mortality. While observational and randomized studies have examined surgical treatment of IMR with conflicting outcomes, additional well-designed randomized controlled trials should be performed to further clarify the optimal treatment for IMR. Additionally, close attention should be paid to the quality of interventions performed, as durable reduction in IMR provides the best hope of a positive clinical outcome. This review focuses on the pathophysiology of IMR, current evidence regarding surgical and transcatheter interventions, and future directions in management of IMR.

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References

  1. Ward ST, Brescia AA, Romano MA, Bolling SF. Congestive heart failure: surgical techniques for functional mitral regurgitation. Operative cardiac surgery (Sixth edition). Boca Raton: CRC Press; 2018.

  2. Brescia AA, Watt T, Bolling SF. Mitral Valve Repair for Congestive Heart Failure. Society of Thoracic Surgeons E-Book. In press.

  3. Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation. 2005;112:745–58.

    PubMed  Google Scholar 

  4. Deja M, Grayburn P, Sun B, et al. Influence of mitral regurgitation repair on survival in the surgical treatment for ischemic heart failure trial. Circulation. 2012;125:2639–48.

    PubMed  PubMed Central  Google Scholar 

  5. Nakai H, Kaku K, Takeuchi M, et al. Different influences of left ventricular remodeling on anterior and posterior mitral leaflet tethering. Circ J. 2012;76:2481–7.

    PubMed  Google Scholar 

  6. 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;107:1135–40.

    PubMed  Google Scholar 

  7. Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of ischemic mitral regurgitation: an experimental evaluation. Circulation. 1991;84:2167–80.

    CAS  PubMed  Google Scholar 

  8. Beaudoin J, Handschumacher MD, Zeng X, et al. Mitral valve enlargement in chronic aortic regurgitation as a compensatory mechanism to prevent functional mitral regurgitation in the dilated left ventricle. J Am Coll Cardiol. 2013;61:1809–16.

    PubMed  PubMed Central  Google Scholar 

  9. Chaput M, Handschumacher MD, Tournoux F, et al. Mitral leaflet adaptation to ventricular remodeling: occurrence and adequacy in patients with functional mitral regurgitation. Circulation. 2008;118:845–52.

    PubMed  PubMed Central  Google Scholar 

  10. Grayburn PA. New concepts in functional mitral regurgitation: it is not just a disease of the left ventricle. J Am Coll Cardiol. 2013;61:1817–9.

    PubMed  Google Scholar 

  11. Hickey MS, Smith LR, Muhlbaier LH, et al. Current prognosis of ischemic mitral regurgitation. Implications for future management. Circulation. 1988;78:I51–9.

    CAS  PubMed  Google Scholar 

  12. Rossi A, Dini FL, Faggiano P, et al. Independent prognostic value of functional mitral regurgitation in patients with heart failure. A quantitative analysis of 1256 patients with ischaemic and non-ischaemic dilated cardiomyopathy. Heart. 2011;97:1675–80.

    PubMed  Google Scholar 

  13. Comin-Colet J, Sánchez-Corral MA, Manito N, et al. Effect of carvedilol therapy on functional mitral regurgitation, ventricular remodeling, and contractility in patients with heart failure due to left ventricular systolic dysfunction. Transplant Proc. 2002;34:177–8.

    CAS  PubMed  Google Scholar 

  14. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline 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. J Am Coll Cardiol. 2014;63:e57–185.

    PubMed  Google Scholar 

  15. Vahanian A, Alfieri O, Andreotti F, et al. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur J Cardiothorac Surg. 2012;42:S1–S44.

    PubMed  Google Scholar 

  16. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147–239.

    PubMed  Google Scholar 

  17. Benjamin MM, Smith RL, Grayburn PA. Ischemic and functional mitral regurgitation in heart failure: natural history and treatment. Curr Cardiol Rep. 2014;16:517.

    PubMed  Google Scholar 

  18. Di Biase L, Auricchio A, Mohanty P, et al. Impact of cardiac resynchronization therapy on the severity of mitral regurgitation. Europace. 2011;13:829–38.

    PubMed  Google Scholar 

  19. Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011;364:1607–16.

    CAS  PubMed  PubMed Central  Google Scholar 

  20. Kang DH, Sun BJ, Kim DH, et al. Percutaneous vs surgical revascularization in patients with ischemic mitral regurgitation. Circulation. 2011;124:S156–62.

    PubMed  Google Scholar 

  21. Acker MA, Parides MK, Perrault LP, et al. Mitral valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014;370:23–32.

    CAS  PubMed  Google Scholar 

  22. Yun KL, Sintek CF, Miller DC, et al. Randomized trial of partial versus complete chordal preservation methods of mitral valve replacement: A preliminary report. Circulation. 1999;100:II90–4.

    CAS  PubMed  Google Scholar 

  23. Bolling SF, Deeb GM, Brunsting LA, Bach DS. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy. J Thorac Cardiovasc Surg. 1995;109:676–82.

    CAS  PubMed  Google Scholar 

  24. Geidel S, Lass M, Krause K, et al. Early and late results of restrictive mitral valve annuloplasty in 121 patients with cardiomyopathy and chronic mitral regurgitation. Thorac Cardiovasc Surg. 2008;56:262–8.

    CAS  PubMed  Google Scholar 

  25. Chen FY, Adams DH, Aranki SF, et al. Mitral valve repair in cardiomyopathy. Circulation. 1998;98:ll124–7.

    Google Scholar 

  26. Calafiore AM, Gallina S, Di Mauro M, et al. Mitral valve procedure in dilated cardiomyopathy: repair or replacement? Ann Thorac Surg. 2001;71:1146–52.

    CAS  PubMed  Google Scholar 

  27. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001;122:1125–41.

    CAS  PubMed  Google Scholar 

  28. Acker MA, Bolling S, Shemin R, et al. Mitral valve surgery in heart failure: insights from the Acorn Clinical Trial. J Thorac Cardiovasc Surg. 2006;132:568–77.

    PubMed  Google Scholar 

  29. Wu AH, Aaronson KD, Bolling SF, Pagani FD, Welch K, Koelling TM. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. J Am Coll Cardiol. 2005;45:381–7.

    PubMed  Google Scholar 

  30. Trichon BH, Glower DD, Shaw LK, et al. Survival after coronary revascularization, with and without mitral valve surgery, in patients with ischemic mitral regurgitation. Circulation. 2003;108:103–10.

    Google Scholar 

  31. 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;138:278–85.

    PubMed  Google Scholar 

  32. Deja MA, Grayburn PA, Sun B, et al. Influence of mitral regurgitation repair on survival in the surgical treatment for ischemic heart failure trial. Circulation. 2012;125:2639–48.

    PubMed  PubMed Central  Google Scholar 

  33. Chan KM, Punjabi PP, Flather M, et al. Coronary artery bypass surgery with or without mitral annuloplasty in moderate functional ischemic mitral regurgitation: final results of the Randomized Ischemic Mitral Evaluation (RIME) trial. Circulation. 2012;126:2502–10.

    PubMed  Google Scholar 

  34. Smith PK, Puskas JD, Ascheim DD, et al. Surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med. 2014;371:2178–88.

    CAS  PubMed  PubMed Central  Google Scholar 

  35. Braun J, van de Veire NR, Klautz RJ, et al. Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure. Ann Thorac Surg. 2008;85:430–6.

    PubMed  Google Scholar 

  36. McGee EC, Gillinov AM, Blackstone EH, et al. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2004;128:916–24.

    PubMed  Google Scholar 

  37. 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;49:2191–201.

    PubMed  Google Scholar 

  38. Magne J, Senechal M, Dumesnil JG, Pibarot P. Ischemic mitral regurgitation: a complex multifaceted disease. Cardiology. 2009;112:244–59.

    PubMed  Google Scholar 

  39. Goldstein D, Moskowitz AJ, Gelijns AC, et al. Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation. N Engl J Med. 2016;374:344–53.

    CAS  PubMed  Google Scholar 

  40. Hueb AC, Jatene FB, Moreira LF, Pomerantzeff PM, Kallás E, de Oliveira SA. Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: new insights from anatomic study. J Thorac Cardiovasc Surg. 2002;124:1216–24.

    PubMed  Google Scholar 

  41. Bach DS, Bolling SF. Early improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy. Am Heart J. 1995;129:1165–70.

    CAS  PubMed  Google Scholar 

  42. Bothe W, Kvitting JP, Stephens EH, et al. Effects of different annuloplasty ring types on mitral leaflet tenting area during acute myocardial ischemia. J Thorac Cardiovasc Surg. 2011;141:345–53.

    PubMed  PubMed Central  Google Scholar 

  43. Lancellotti P, Moura L, Pierard LA, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: Mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr. 2010;11:307–32.

    PubMed  Google Scholar 

  44. Kron IL, Hung J, Overbey JR, et al. Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2015;149:752–61.

    PubMed  Google Scholar 

  45. Feldman T, Foster E, Glower D, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364:1395–406.

    CAS  PubMed  Google Scholar 

  46. Mauri L, Foster E, Glower DD, et al. Four-year results of a randomized controlled trial of percutaneous repair vs surgery for mitral regurgitation. J Am Coll Cardiol. 2013;62:317–28.

    PubMed  Google Scholar 

  47. Glower DD, Kar S, Trento A, et al. Percutaneous mitral valve repair for mitral regurgitation in high-risk patients: results of the EVEREST II study. J Am Coll Cardiol. 2014;64:172–81.

    PubMed  Google Scholar 

  48. Foster E, Kwan D, Feldman T, et al. Percutaneous mitral valve repair in the initial EVEREST cohort: evidence of reverse left ventricular remodeling. Circ Cardiovasc Imaging. 2013;6:522–30.

    PubMed  Google Scholar 

  49. Grayburn PA, Foster E, Sangli C, et al. Relationship between the magnitude of reduction in mitral regurgitation severity and left ventricular and left atrial reverse remodeling after MitraClip therapy. Circulation. 2013;128:1667–74.

    PubMed  Google Scholar 

  50. Auricchio A, Schillinger W, Meyer S, et al. PERMIT-CARE Investigators. Correction of mitral regurgitation in nonresponders to cardiac resynchronization therapy by MitraClip improves symptoms and promotes reverse remodeling. J Am Coll Cardiol. 2011;58:2183–9.

    PubMed  Google Scholar 

  51. Obadia JF, Messika-Zeitoun D, Leurent G, et al. MITRA-FR Investigators. Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation. N Engl J Med. 2018;379:2297–306.

    PubMed  Google Scholar 

  52. Stone GW, Lindenfeld J, Abraham WT, et al. COAPT Investigators. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. N Engl J Med. 2018;379:2307–18.

    PubMed  Google Scholar 

  53. A Clinical Evaluation of the Safety and Effectiveness of the MitraClip System in the Treatment of Clinically Significant Functional Mitral Regurgitation (Reshape-HF2). Available from: https://clinicaltrials.gov/ct2/show/NCT02444338. ClinicalTrials.gov Identifier: NCT02444338. Accessed 23 Dec 2018.

  54. Feldman T, Young A. Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 2014;63:2057–68.

    PubMed  Google Scholar 

  55. Sorini Dini C, Landi D, Meucci F, Di Mario C. Unexpected delayed complete atrioventricular block after Cardioband Implantation. Catheter Cardiovasc Interv. 2018;92:1201–4.

    PubMed  Google Scholar 

  56. Rogers JH, Boyd WD, Smith TWR, Ebner AA, Bolling SF. Combined MitraClip Edge-to-Edge Repair With Millipede IRIS Mitral Annuloplasty. JACC Cardiovasc Interv. 2018;11:323–4.

    PubMed  Google Scholar 

  57. Jorbenadze R, Schreieck J, Barthel C, et al. Percutaneous Edge-to-Edge Mitral Valve Repair Using the New MitraClip XTR System. JACC Cardiovasc Interv. 2018;11:e93–5.

    PubMed  Google Scholar 

  58. Regueiro A, Granada JF, Dagenais F, Rodes-Cabau J. Transcatheter mitral valve replacement: insights from early clinical experience and future challenges. J Am Coll Cardiol. 2017;69:2175–92.

    PubMed  Google Scholar 

  59. Lavall D, Hagendorff A, Schirmer SH, Bohm M, Borger MA, Laufs U. Mitral valve interventions in heart failure. ESC Heart Fail. 2018;5:552–61.

    PubMed  PubMed Central  Google Scholar 

  60. Yoon SH, Whisenant BK, Bleiziffer S, et al. Transcatheter mitral valve replacement for degenerated bioprosthetic valves and failed annuloplasty rings. J Am Coll Cardiol. 2017;70:1121–31.

    PubMed  Google Scholar 

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Funding

Alexander Brescia is supported by the National Institutes of Health National Research Service Award postdoctoral fellowship (No. 5T32HL076123).

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Authors and Affiliations

  1. Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA

    Alexander Angelo Brescia, Tessa Maria Fontana Watt & Steven Frederic Bolling

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  1. Alexander Angelo Brescia
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  2. Tessa Maria Fontana Watt
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  3. Steven Frederic Bolling
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Correspondence to Alexander Angelo Brescia.

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Brescia, A.A., Watt, T.M.F. & Bolling, S.F. Ischemic mitral regurgitation: current understanding and surgical options. Indian J Thorac Cardiovasc Surg 36 (Suppl 1), 27–33 (2020). https://doi.org/10.1007/s12055-019-00811-4

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