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Ischemic Mitral Regurgitation: Unusual Approaches for Correction

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Abstract

Ischemic mitral regurgitation (MR) results from ischemic left ventricular distortion with tethering of the mitral leaflets. The standard surgical therapy for ischemic MR is mitral ring annuloplasty, often performed at the time of coronary artery bypass surgery. However, ring annuloplasty is associated with an up to 30% recurrence rate of MR, as it does not directly address ventricular distortion and tethering of the mitral leaflets and there is often further ventricular remodeling following bypass surgery. This article reviews the background and mechanism of ischemic MR and unusual approaches to this important yet difficult to treat valvular problem.

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References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. Cohn LH, Rizzo RJ, Adams DH, et al.: The effect of pathophysiology on the surgical treatment of ischemic mitral regurgitation: operative and late risks of repair versus replacement. Eur J Cardiothorac Surg 1995, 9:568–574.

    Article  CAS  PubMed  Google Scholar 

  2. Frater R, Cornelissen P, Sisto D: Mechanisms of ischemic mitral insufficiency and their surgical correction. In Ischemic Mitral Incompetence. Edited by Vetter H, Hetzer R, Schmutzler H. New York: Springer-Verlag; 1991:117–130.

  3. Rankin JS, Hickey MS, Smith LR, et al.: Ischemic mitral regurgitation. Circulation 1989, 79:I116–I121.

    CAS  PubMed  Google Scholar 

  4. Lamas GA, Mitchell GF, Flaker GC, et al.: Clinical significance of mitral regurgitation after acute myocardial infarction. Survival and Ventricular Enlargement Investigators. Circulation 1997, 96:827–833.

    CAS  Google Scholar 

  5. Grigioni F, Enriquez-Sarano M, Zehr KJ, et al.: Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 2001, 103:1759–1764.

    CAS  PubMed  Google Scholar 

  6. Stevenson LW, Bellil D, Grover-McKay M, et al.: Effects of afterload reduction (diuretics and vasodilators) on left ventricular volume and mitral regurgitation in severe congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 1987, 60:654–658.

    Article  CAS  PubMed  Google Scholar 

  7. Junker A, Thayssen P, Nielsen B, Andersen PE: The hemodynamic and prognostic significance of echo-Doppler-proven mitral regurgitation in patients with dilated cardiomyopathy. Cardiology 1993, 83:14–20.

    Article  CAS  PubMed  Google Scholar 

  8. Koelling TM, Aaronson KD, Cody RJ, et al.: Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 2002, 144:524–529.

    Article  PubMed  Google Scholar 

  9. Godley RW, Wann LS, Rogers EW, et al.: Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation 1981, 63:565–571.

    CAS  PubMed  Google Scholar 

  10. Ogawa S, Hubbard FE, Mardelli TJ, Dreifus LS: Cross-sectional echocardiographic spectrum of papillary muscle dysfunction. Am Heart J 1979, 97:312–321.

    Article  CAS  PubMed  Google Scholar 

  11. He S, Fontaine AA, Schwammenthal E, et al.: Integrated mechanism for functional mitral regurgitation: leaflet restriction versus coapting force: in vitro studies. Circulation 1997, 96:1826–1834.

    CAS  PubMed  Google Scholar 

  12. Otsuji Y, Handschumacher MD, Schwammenthal E, et al.: Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation 1997, 96:1999–2008.

    CAS  PubMed  Google Scholar 

  13. Llaneras MR, Nance ML, Streicher JT, et al.: Pathogenesis of ischemic mitral insufficiency. J Thorac Cardiovasc Surg 1993, 105:439–442; discussion 442–443.

    Google Scholar 

  14. Llaneras MR, Nance ML, Streicher JT, et al.: Large animal model of ischemic mitral regurgitation. Ann Thorac Surg 1994, 57:432–439.

    Article  CAS  PubMed  Google Scholar 

  15. Otsuji Y, Handschumacher MD, Liel-Cohen N, et al.: Mechanism of ischemic mitral regurgitation with segmental left ventricular dysfunction: three-dimensional echocardiographic studies in models of acute and chronic progressive regurgitation. J Am Coll Cardiol 2001, 37:641–648.

    Article  CAS  PubMed  Google Scholar 

  16. Lai DT, Tibayan FA, Myrmel T, et al.: Mechanistic insights into posterior mitral leaflet inter-scallop malcoaptation during acute ischemic mitral regurgitation. Circulation 2002, 106(Suppl 1):I40–I45.

    PubMed  Google Scholar 

  17. Yiu SF, Enriquez-Sarano M, Tribouilloy C, et al.: Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation 2000, 102:1400–1406.

    CAS  PubMed  Google Scholar 

  18. Otsuji Y, Kumanohoso T, Yoshifuku S, et al.: Isolated annular dilation does not usually cause important functional mitral regurgitation: comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy. J Am Coll Cardiol 2002, 39:1651–1656.

    Article  PubMed  Google Scholar 

  19. Aklog L, Flores KQ, Chen RH, et al.: Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation 2000, 102:II–492.

    Google Scholar 

  20. Hung J, Handschumacher MD, Rudski L, et al.: Persistence of ischemic mitral regurgitation despite annular ring reduction: mechanistic insights from 3D echocardiography. Circulation 1999, 100:73.

    Google Scholar 

  21. Liel-Cohen N, Otsuji Y, Vlahakes GJ, et al.: Functional ischemic mitral regurgitation can persist despite ring annuloplasty: mechanistic insights. Circulation 1997, 96:I–540.

    Google Scholar 

  22. Calafiore AM, Gallina S, Di Mauro M, et al.: Mitral valve procedure in dilated cardiomyopathy: repair or replacement? Ann Thorac Surg 2001, 71:1146–1152; discussion 1152–1153.

    Google Scholar 

  23. Tahta SA, Oury JH, Maxwell JM, et al.: Outcome after mitral valve repair for functional ischemic mitral regurgitation. J Heart Valve Dis 2002, 11:11–18; discussion 18–19.

    Google Scholar 

  24. McGee EC, Gillinov AM, Blackstone EH, et al.: Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2004, 128:916–924.

    PubMed  Google Scholar 

  25. Hung J, Papakostas L, Tahta SA, et al.: Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 2004, 110(Suppl 1):II85–II90.

    Google Scholar 

  26. Kuwahara E: Mechanism of recurrent/persistent ischemic/functional mitral regurgitation in the chronic phase after surgical annuloplasty: importance of augmented posterior leaflet tethering. Circulation 2006, 114(1 Suppl):I529.

    PubMed  Google Scholar 

  27. Messas E, Guerrero JL, Handschumacher MD, et al.: Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation 2001, 104:1958–1963.

    Article  CAS  PubMed  Google Scholar 

  28. •• Borger MA, Murphy PM, Alam A, et al.: Initial results of the chordal-cutting operation for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2007, 133:1483–1492. This study summarizes the largest clinical experience with chordal cutting.

    Article  PubMed  Google Scholar 

  29. •• Liel-Cohen N, Guerrero JL, Otsuji Y, et al.: Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: insights from 3-dimensional echocardiography. Circulation 2000, 101:2756–2763. This was the initial experimental study proposing a ventricular approach to treating ischemic MR.

    CAS  PubMed  Google Scholar 

  30. Hung J, Guerrero JL, Handschumacher MD, et al.: Reverse ventricular remodeling reduces ischemic mitral regurgitation: echo-guided device application in the beating heart. Circulation 2002, 106:2594–2600.

    Article  PubMed  Google Scholar 

  31. Hvass U, Tapia M, Baron F, et al.: Papillary muscle sling: a new functional approach to mitral repair in patients with ischemic left ventricular dysfunction and functional mitral regurgitation. Ann Thorac Surg 2003, 75:809–811.

    Article  PubMed  Google Scholar 

  32. Menicanti L, Di Donato M, Frigiola A, et al.: Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg 2002, 123:1041–1050.

    Article  CAS  PubMed  Google Scholar 

  33. Rama A, Praschker L, Barreda E, Gandjbakhch I: Papillary muscle approximation for functional ischemic mitral regurgitation. Ann Thorac Surg 2007, 84:2130–2131.

    Article  PubMed  Google Scholar 

  34. Fukamachi K, Inoue M, Popović ZB, et al.: Off-pump mitral valve repair using the Coapsys device: a pilot study in a pacing-induced mitral regurgitation model. Ann Thorac Surg 2004, 77:688–692.

    Article  PubMed  Google Scholar 

  35. Mishra YK, Mittal S, Jaguri P, Trehan N: Coapsys mitral annuloplasty for mitral regurgitation. One year results. Ann Thorac Surg 2006, 81:42–46.

    Article  Google Scholar 

  36. •• Hung J, Solis J, Guerrero JL, et al.: A novel approach for reducing ischemic mitral regurgitation by injection of a polymer to reverse remodel and reposition displaced papillary muscles. Circulation 2008, 118(14 Suppl):S263–S269. This study presents experimental evidence for a polymer-based approach to reverse remodel the ventricle.

    Article  PubMed  Google Scholar 

  37. Ottavio AJ, Marsano F, DeBonis M, et al.: The double-orifice technique in mitral valve repair: A simple solution for complex problems. J Thorac Cardiovasc Surg 2001, 122:674-681.

    Article  Google Scholar 

  38. Feldman T, Wasserman HS, Hermann HC, et al.: Percutaneous mitral valve repair using the edge-to-edge technique: six month results of the EVEREST Phase I Clinical Trial. J Am Coll Cardiol 2005, 46:2134–2140.

    Article  PubMed  Google Scholar 

  39. Maud L, Gaarg P, Massaro J, et al.: The EVEREST II Trial: Design and rationale for a randomized study of the Evalve Mitraclip system compared with mitral valve surgery for mitral regurgitation. Am Heart J 2010, 160:23–29.

    Article  Google Scholar 

  40. Kron IL, Green GR, Cope JT: Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation. Ann Thorac Surg 2002, 74:600–601.

    Article  PubMed  Google Scholar 

  41. Menicanti L, Di Donato M, Frigiola A: Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg 2002, 123:1041–1050.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, MA, USA

    Judy Hung

  2. Harvard Medical School, Boston, MA, USA

    Judy Hung

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  1. Judy Hung
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Correspondence to Judy Hung.

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Hung, J. Ischemic Mitral Regurgitation: Unusual Approaches for Correction. Curr Cardiovasc Imaging Rep 3, 396–402 (2010). https://doi.org/10.1007/s12410-010-9043-7

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  • DOI: https://doi.org/10.1007/s12410-010-9043-7

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