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JeanJean--Louis J. Vanoverschelde, MD,Louis J. Vanoverschelde, MD, PhDPhD
Ischemic Ischemic Mitral RegurgitationMitral Regurgitation
UniversitUniversitéé catholique decatholique de LouvainLouvainBrusselsBrussels,, BelgiumBelgium
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationDefinitionDefinition
Ischemic mitral regurgitation is mitral regurgitation due to Ischemic mitral regurgitation is mitral regurgitation due to complications of coronary artery disease, in particular, myocardcomplications of coronary artery disease, in particular, myocardial ial infarction, and not the fortuitous association of coronary arterinfarction, and not the fortuitous association of coronary artery y disease with intrinsic valve disease such as rheumatic disease, disease with intrinsic valve disease such as rheumatic disease, or or mitral valve prolapse.mitral valve prolapse.
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• In the acute phase of myocardial infarction, ischemic mitral In the acute phase of myocardial infarction, ischemic mitral regurgitaion is frequent and appears to carry an adverse prognosregurgitaion is frequent and appears to carry an adverse prognosis.is.
•• In the chronic postIn the chronic post--myocardial infarction phase, angiographic myocardial infarction phase, angiographic mitral regurgitaion is frequent (> 19% grade II MR) and is mitral regurgitaion is frequent (> 19% grade II MR) and is predictive of survival, even if mild to moderate in severity. predictive of survival, even if mild to moderate in severity.
•• For diagnosis purposes, murmur is of limited value. Objective For diagnosis purposes, murmur is of limited value. Objective methods are therefore required.methods are therefore required.
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationPrognostic value of MR in ischemic heart diseasePrognostic value of MR in ischemic heart disease
•• 303 patients (mean age 70 303 patients (mean age 70 ±± 10 yrs) with a first Q10 yrs) with a first Q--wave wave MI older than 16 days before baseline assessment.MI older than 16 days before baseline assessment.
•• Exclusion criteria :Exclusion criteria :
•• MI MI ≤≤ 16 days16 days•• Previous surgeryPrevious surgery•• Papillary muscle rupturePapillary muscle rupture•• MR of organic originMR of organic origin•• Significant ARSignificant AR
Grigioni et al., Grigioni et al., CirculationCirculation. 2001;103:1759.. 2001;103:1759.
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
IMR IMR no IMRno IMR p valuep value(n=194)(n=194) (n=109) (n=109)
Age, y Age, y 7171±±11 11 7070±±99 0.200.20Men Men 135 (70%)135 (70%) 86 (79%)86 (79%) 0.080.08NYHA IIINYHA III––IV IV 92 (47%)92 (47%) 38 (35%) 38 (35%) 0.0340.034A. Fib.A. Fib. 30 (15%)30 (15%) 5 (5%)5 (5%) 0.0040.004SBPSBP 132132±±2626 141141±±2626 0.0040.004Anterior MIAnterior MI 40 (21%)40 (21%) 44 (40%)44 (40%) 0.0010.001EF, %EF, % 3333±±1414 3434±±1111 0.140.14LVS, mm/mLVS, mm/m²² 2828±±66 2626±±66 0.0030.003LVD, mm/mLVD, mm/m²² 3333±±55 3131±±55 0.0010.001
Grigioni et al., Grigioni et al., CirculationCirculation. 2001;103:1759.. 2001;103:1759.
Prognostic value of MR in ischemic heart diseasePrognostic value of MR in ischemic heart disease
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
Time (Time (monthsmonths))
Surv
ival
Surv
ival
(%)
(%)
00 1212 2424 3636 4848 606000
2020
4040
6060
8080
100100
6161±±6%6%
3838±±5%5%
MI MI without without MRMR
MI MI with with MRMR
P<0.001P<0.001
PrognosticPrognostic value value ofof MR in MR in ischemicischemic heartheart diseasedisease
Grigioni et al., Grigioni et al., CirculationCirculation. 2001;103:1759.. 2001;103:1759.
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
RRRR 95% CI 95% CI p valuep value
Age Age 1.031.03 1.011.01--1.051.05 < 0.001< 0.001
EFEF 0.980.98 0.970.97--1.001.00 0.0300.030
NYHA IIINYHA III--IVIV 1.881.88 1.271.27--2.792.79 0.0020.002
DiabetesDiabetes 1.481.48 0.990.99--2.202.20 0.0540.054
A. Fib.A. Fib. 1.621.62 1.001.00--2.622.62 0.0490.049
1/Creatinine1/Creatinine 0.440.44 0.210.21--0.940.94 0.0340.034
R. Vol. < 30 mLR. Vol. < 30 mL 1.641.64 0.980.98--2.752.75 0.0590.059
R. Vol. R. Vol. ≥≥ 30 mL30 mL 2.052.05 1.301.30--3.233.23 0.0020.002
Multivariate predictors of overall survivalMultivariate predictors of overall survival
Grigioni et al., Grigioni et al., CirculationCirculation. 2001;103:1759.. 2001;103:1759.
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
ERO > 20 mmERO > 20 mm22
andand/or/orRV > 30 mLRV > 30 mL
adjustedadjusted RR: 2.01 RR: 2.01 -- 2.382.38
PrognosticPrognostic value value ofof MR in MR in ischemicischemic heartheart diseasedisease
Grigioni et al., Grigioni et al., CirculationCirculation. 2001;103:1759.. 2001;103:1759.
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationPrognosticPrognostic value value ofof MR in MR in ischemicischemic heartheart diseasedisease
Grigioni et al., Grigioni et al., CirculationCirculation. 2001;103:1759.. 2001;103:1759.
Time (Time (monthsmonths))
Surv
ival
Surv
ival
(%)
(%)
00 1212 2424 3636 4848 606000
2020
4040
6060
8080
100100
6161±±6%6%
3636±±7%7%
RVolRVol
0011--2929> 30> 30 P < 0.0001P < 0.0001
4444±±9%9%
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationPrognosticPrognostic value value ofof MR in MR in ischemicischemic heartheart diseasedisease
Grigioni et al., Grigioni et al., CirculationCirculation. 2001;103:1759.. 2001;103:1759.
Time (Time (monthsmonths))
Surv
ival
Surv
ival
(%)
(%)
00 1212 2424 3636 4848 606000
2020
4040
6060
8080
100100
6161±±6%6%
2929±±9%9%
EROERO
0011--1919> 20> 20 P < 0.0001P < 0.0001
4747±±8%8%
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
Time (years)Time (years)
Inci
denc
e of
CH
F (%
)In
cide
nce
of C
HF
(%)
00 11 22 33 44 6600
2020
4040
6060
8080
100100
5353±±7%7%
1818±±5%5%
MI MI without without MRMR
MI MI with with MRMR
P<0.001P<0.001
Impact of iMRImpact of iMR on the development of heart failureon the development of heart failure
Grigioni et al., Grigioni et al., J Am Coll CardiolJ Am Coll Cardiol. 2005;45:260.. 2005;45:260.
55
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
Time (years)Time (years)
Inci
denc
e of
CH
F (%
)In
cide
nce
of C
HF
(%)
00 11 22 33 44 6600
2020
4040
6060
8080
100100
1818±±5%5%
P<0.001P<0.001
Impact of iMRImpact of iMR on the development of heart failureon the development of heart failure
Grigioni et al., Grigioni et al., J Am Coll CardiolJ Am Coll Cardiol. 2005;45:260.. 2005;45:260.
55
EROERO
0011--1919> 20> 20
4646±±9%9%
6868±±12%12%
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
TypeType IIannularannular dilatationdilatation
Ischemic mitralIschemic mitral regurgitation: Type I dysfunctionregurgitation: Type I dysfunction
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemic mitralIschemic mitral regurgitation: Type II dysfunctionregurgitation: Type II dysfunction
Type IIType IIPapillary muscle Papillary muscle
rupturerupture
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemic mitralIschemic mitral regurgitation: Type II dysfunctionregurgitation: Type II dysfunction
Type IIType IIPapillary muscle Papillary muscle
elongationelongation
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
Type IIIbType IIIbLeafletLeaflet restrictionrestriction
Ischemic mitralIschemic mitral regurgitation: Type III dysfunctionregurgitation: Type III dysfunction
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• Incomplete leafletIncomplete leaflet and scallop coaptationand scallop coaptation-- Decreased closing forcesDecreased closing forces-- Annular dilatation and loss of annular contractionAnnular dilatation and loss of annular contraction-- Increased tethering forcesIncreased tethering forces
IschemicIschemic mitralmitral regurgitation: Decreased closing forcesregurgitation: Decreased closing forces
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• Incomplete leafletIncomplete leaflet and scallop coaptationand scallop coaptation-- Decreased closing forcesDecreased closing forces-- Annular dilatation and loss of annular contractionAnnular dilatation and loss of annular contraction-- Increased tethering forcesIncreased tethering forces
IschemicIschemic mitralmitral regurgitation: Decreased closing forcesregurgitation: Decreased closing forces
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemic mitral regurgitation:Ischemic mitral regurgitation: Decreased closing forcesDecreased closing forces
1010
66
44
22
00
88
00 +1+1 +2+2 +3+3 +4+4
16001600
12001200
800800
400400
00
00 +1+1 +2+2 +3+3 +4+4
DegreeDegree of MRof MR DegreeDegree of MRof MR
Coa
ptat
ion
dist
ance
(cm
)C
oapt
atio
n di
stan
ce (c
m)
LVLV
dPdP// d
tdt(( m
mH
gm
mH
g /s)/s)
r=0.99r=0.99P<0.0001P<0.0001
r=r=--0.940.94P<0.0001P<0.0001
KaulKaul et al., et al., Circulation Circulation 1991;84:21671991;84:2167
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• Incomplete leafletIncomplete leaflet and scallop coaptationand scallop coaptation-- Decreased closing forcesDecreased closing forces-- Annular dilatation and loss of annular contractionAnnular dilatation and loss of annular contraction-- Increased tethering forcesIncreased tethering forces
IschemicIschemic mitralmitral regurgitation: Annular dilatationregurgitation: Annular dilatation
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemicIschemic mitral regurgitation: Annular dilatationmitral regurgitation: Annular dilatation
TimekTimek et al., et al., Circulation Circulation 2002;106 (suppl I):I2002;106 (suppl I):I--3333
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
--400400 --300300 --200200 --100100 00 100100 200200 300300 400400
11.211.2
10.810.8
10.410.4
10.010.0
9.89.8
Time (ms)Time (ms)
Ann
ular
per
imet
er (c
m)
Ann
ular
per
imet
er (c
m)
Ischemic mitral regurgitation: Annular dilatationIschemic mitral regurgitation: Annular dilatation
TimekTimek et al., et al., Circulation Circulation 2002;106 (suppl I):I2002;106 (suppl I):I--3333
baselinebaseline
ischemiaischemia
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemic mitralIschemic mitral regurgitation: Posterior commissure involvementregurgitation: Posterior commissure involvement
ACAC
P1P1
P2P2 P3P3
PCPC
A1A1
A2A2 A3A3
P3P3
NormalNormal IschemicIschemic
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemic mitralIschemic mitral regurgitation: Posterior commissure involvementregurgitation: Posterior commissure involvement
P3P3
IschemicIschemic
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
He and al. He and al. J Heart Valve DisJ Heart Valve Dis 1999;8:2941999;8:294
AnnulusAnnulus size (times normal)size (times normal)
MR
vol
ume
(mL)
MR
vol
ume
(mL)
00
55
1010
1515
2020
2525
3030
Ischemic mitral regurgitation: Annular dilatationIschemic mitral regurgitation: Annular dilatation
0.80.8 1.01.0 1.21.2 1.41.4 1.61.6 2.02.0 2.22.21.81.8
Normal PM positionNormal PM position
Symmetrical PM tetheringSymmetrical PM tethering
Anterior PM tetheringAnterior PM tethering
Posterior PM tetheringPosterior PM tethering
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• Incomplete leafletIncomplete leaflet and scallop coaptationand scallop coaptation-- Decreased closing forcesDecreased closing forces-- Annular dilatation and loss of annular contractionAnnular dilatation and loss of annular contraction-- Increased tethering forcesIncreased tethering forces
IschemicIschemic mitralmitral regurgitation: Increased tentingregurgitation: Increased tenting
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
YiuYiu et al., et al., Circulation Circulation 2000;102:14002000;102:1400
Ischemic mitral regurgitation: Increased tentingIschemic mitral regurgitation: Increased tenting
Tenting areaTenting area
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
YiuYiu et al., et al., Circulation Circulation 2000;102:14002000;102:1400
33 8877665544 99 131311111010 1212
00
9090
8080
7070
6060
5050
4040
3030
2020
1010
00 252520201515101055 3030 40403535
00
9090
8080
7070
6060
5050
4040
3030
2020
1010
ER
O (m
mE
RO
(mm
22 ))
Tenting areaTenting area (cm(cm22)) AnnularAnnular contraction (%)contraction (%)
r=0.74r=0.74p<0.0001p<0.0001
r=r=--0.610.61p<0.0001p<0.0001
Ischemic mitral regurgitation: Increased tentingIschemic mitral regurgitation: Increased tenting
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
YiuYiu et al., et al., Circulation Circulation 2000;102:14002000;102:1400
44 9988776655 1010
33
1313
1212
1111
1010
99
88
77
66
55
44
Ten
ting
area
Ten
ting
area
(cm
(cm
22 ))
PPM PPM -- fibrosafibrosa distance (mm)distance (mm)
r=0.75r=0.75p<0.0001p<0.0001
Ischemic mitral regurgitation: Increased tentingIschemic mitral regurgitation: Increased tenting
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemic mitral regurgitation: Asymmetrical vs symmetrical tentiIschemic mitral regurgitation: Asymmetrical vs symmetrical tentingng
AgricolaAgricola et al., et al., Eur J EchocardiogrEur J Echocardiogr 20020044;;55::326326
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemic mitral regurgitation: Asymmetrical vs symmetrical tentiIschemic mitral regurgitation: Asymmetrical vs symmetrical tentingng
AgricolaAgricola et al., et al., Eur J EchocardiogrEur J Echocardiogr 20020044;;55::326326
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemicIschemic mitral mitral regurgitationregurgitation: : AsymmetricalAsymmetrical tentingtenting -- thethe seagullseagull signsign
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationIschemic mitral regurgitation: Asymmetrical tentingIschemic mitral regurgitation: Asymmetrical tenting -- the seagull signthe seagull sign
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
restrest
exerciseexercise
Pt #1Pt #1 Pt #2Pt #2 Pt #3Pt #3
ExerciseExercise--induced changes in MR severity in dilated cardiomyopathyinduced changes in MR severity in dilated cardiomyopathy
LapuLapu--BulaBula et al., et al., Circulation Circulation 2002;2002;106:1342106:1342
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
Changes inChanges in strokestroke volume (ml/beat)volume (ml/beat)--3030 --2525 --2020 --1515 --1010 --55 00 55 1010 1515 2020 2525 3030 3535 4040 4545 5050
% c
hang
es in
%
cha
nges
in
mitr
alm
itral
regu
rgita
tion
regu
rgita
tion
00
55
1010
1515
2020
2525
3030
3535
4040
N=25N=25r=r=--0.870.87
ExerciseExercise--induced changes in MR severity in dilated cardiomyopathyinduced changes in MR severity in dilated cardiomyopathy
LapuLapu--BulaBula et al., et al., Circulation Circulation 2002;2002;106:1342106:1342
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationImpact of exerciseImpact of exercise--induced mitral regurgitation on exercise toleranceinduced mitral regurgitation on exercise tolerance
LapuLapu--BulaBula et al., et al., Circulation Circulation 2002;2002;106:1342106:1342
Changes in pulmonary wedge pressure (mmHg)Changes in pulmonary wedge pressure (mmHg)
00 1010 2020 3030 4040 5050
N = 25N = 25r = 0.62r = 0.62
% c
hang
es in
%
cha
nges
in
mitr
alm
itral
regu
rgita
tion
regu
rgita
tion
00
55
1010
1515
2020
2525
3030
3535
4040
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationImpact of exerciseImpact of exercise--induced mitral regurgitation on exercise toleranceinduced mitral regurgitation on exercise tolerance
LapuLapu--BulaBula et al., et al., Circulation Circulation 2002;2002;106:1342106:1342
% c
hang
es in
%
cha
nges
in
mitr
alm
itral
regu
rgita
tion
regu
rgita
tion
00
55
1010
1515
2020
2525
3030
3535
4040
44 66 88 1010 1212 1414 1616 1818 2020 2222
N = 25N = 25r = r = --0.670.67
VOVO22 max (mL/kg/min)max (mL/kg/min)
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
LapuLapu--BulaBula et al., et al., Circulation Circulation 2002;2002;106:1342106:1342
Exe
rcis
e M
R (%
)E
xerc
ise
MR
(%)
Exercise Exercise coaptationcoaptation distancedistance(cm)(cm)
00 55 1010 1515 2020 2525 3030 3535 404000
1010
2020
3030
4040
5050
6060
7070
8080
% c
hang
es in
MR
sev
erity
% c
hang
es in
MR
sev
erity
% changes in% changes in coaptationcoaptation distancedistance00 2020 4040 6060 8080
00
55
1010
1515
2020
2525
3030
3535
4040r=0.86r=0.86p<0.001p<0.001
r=0.81r=0.81p<0.001p<0.001
ExerciseExercise--induced changes in MR severity in dilated cardiomyopathyinduced changes in MR severity in dilated cardiomyopathy
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
Time (Time (monthsmonths))
Surv
ival
Surv
ival
(%)
(%)
00 1212 1818 2424 3030 363600
2020
4040
6060
8080
100100∆∆ ERO < 13 mmERO < 13 mm²²
∆∆ ERO ERO ≥≥ 13 mm13 mm²²
P<0.0011P<0.0011
PrognosticPrognostic value value ofof MR in MR in ischemicischemic heartheart diseasedisease
Lancellotti et al., Lancellotti et al., CirculationCirculation 2003;108:1713.2003;108:1713.
66
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• Restore leafletRestore leaflet and scallop coaptationand scallop coaptation-- Improve closing forcesImprove closing forces-- Reduce annular sizeReduce annular size-- Decrease tethering forcesDecrease tethering forces
Treatment of ischemicTreatment of ischemic mitralmitral regurgitationregurgitation
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• Restore leafletRestore leaflet and scallop coaptationand scallop coaptation-- Improve closing forcesImprove closing forces-- Reduce annular sizeReduce annular size-- Decrease tethering forcesDecrease tethering forces
Treatment of ischemicTreatment of ischemic mitralmitral regurgitationregurgitation
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
AklogAklog et al., et al., Circulation Circulation 2001;104:I682001;104:I68
Treatment of ischemic MR: Role of Treatment of ischemic MR: Role of CABGCABG
% o
f pat
ient
s%
of p
atie
nts
00 2+2+1+1+ 3+3+ 4+4+
IntraIntra--opop TEETEE
6060
3030
2020
1010
00
5050
4040
29%29%
53%53%
8%8%11%11%
% o
f pat
ient
s%
of p
atie
nts
00 2+2+1+1+ 3+3+ 4+4+
PostPost--opop TEETEE
6060
3030
2020
1010
00
5050
4040
4%4%
51%51%
4%4%
37%37%
3%3%
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• Restore leafletRestore leaflet and scallop coaptationand scallop coaptation-- Improve closing forcesImprove closing forces-- Reduce annular sizeReduce annular size-- Decrease tethering forcesDecrease tethering forces
Treatment of ischemicTreatment of ischemic mitralmitral regurgitationregurgitation
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
HungHung et al., et al., Circulation Circulation 20042004;;110110::IIII--8585
Restrictive annuloplasty does not prevent recurrence of ischemicRestrictive annuloplasty does not prevent recurrence of ischemic MRMR
Ven
a co
ntra
cta
(cm
)V
ena
cont
ract
a (c
m)
Early postEarly post--op op LVESD = 58 mmLVESD = 58 mm
Late postLate post--op op LVESD = 73 mmLVESD = 73 mm
EarlyEarlypostpost--opop
PerPer--opopPrePre--opop LateLatepostpost--opop
0.00.0
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
p=0.009p=0.009
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
GuyGuy et al., et al., J Am Coll CardiolJ Am Coll Cardiol 20042004;;4343::377377
Late Late postpost--opop
EarlyEarlypostpost--opop
PrePre--opop7070
110110
100100
9090
8080
LVE
SV (m
L)LV
ESV
(mL)
Restrictive annuloplasty does not prevent LV remodelingRestrictive annuloplasty does not prevent LV remodeling
ES
sher
icity
inde
xE
S sh
eric
ity in
dex
0.250.25
0.450.45
0.400.40
0.350.35
0.300.30
Late Late postpost--opop
EarlyEarlypostpost--opop
PrePre--opop
p=0.02p=0.02 p=0.03p=0.03
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
•• Restore leafletRestore leaflet and scallop coaptationand scallop coaptation-- Improve closing forcesImprove closing forces-- Reduce annular sizeReduce annular size-- Decrease tethering forcesDecrease tethering forces
Treatment of ischemicTreatment of ischemic mitralmitral regurgitationregurgitation
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationTreatment of ischemic MR: Secondary chordae cuttingTreatment of ischemic MR: Secondary chordae cutting
MessasMessas et al., et al., Circulation Circulation 2001;104:19582001;104:1958
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
baselinebaseline inferiorinferior ischemiaischemia inferiorinferior + PM+ PMchordae cuttingchordae cutting
Treatment of ischemic MR: Secondary chordae cuttingTreatment of ischemic MR: Secondary chordae cutting
MessasMessas et al., et al., Circulation Circulation 2001;104:19582001;104:1958
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
MessasMessas et al., et al., Circulation Circulation 2001;104:19582001;104:1958
Treatment of ischemic MR: Secondary chordae cuttingTreatment of ischemic MR: Secondary chordae cutting
Leaflet covering areaLeaflet covering area (cm(cm22))
MR
MR
stro
kest
roke
volu
me
(mL/
beat
)vo
lum
e (m
L/be
at)
00
22
44
66
88
1010
5.55.5 66 6.56.5 77 7.57.5 88 998.58.5
Ischemic Mitral RegurgitationIschemic Mitral RegurgitationAnteriorAnterior leafletleaflet restriction: restriction: secondarysecondary chordschords excisionexcision
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
suturesuturerowsrows
infarctinfarctzonezone
LienLien--Cohen et al., Cohen et al., Circulation Circulation 2000;101:27562000;101:2756
Treatment of ischemic MR: Infarct plicationTreatment of ischemic MR: Infarct plication
PlicationPlication
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
ChronicChronic MIMI Acute plicationAcute plication Chronic plicationChronic plication
LienLien--Cohen et al., Cohen et al., Circulation Circulation 2000;101:27562000;101:2756
Treatment of ischemic MR: Infarct plicationTreatment of ischemic MR: Infarct plication
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
LienLien--Cohen et al., Cohen et al., Circulation Circulation 2000;101:27562000;101:2756
Treatment of ischemic MR: Infarct plicationTreatment of ischemic MR: Infarct plication
1010
66
44
22
00
88
MR
vol
ume
(mL/
beat
)M
R v
olum
e (m
L/be
at)
11 3322 44 55
1616
88
44
00
1212
Cha
nge
inC
hang
e in
teth
erin
gte
ther
ing
dist
ance
(mm
)di
stan
ce (m
m)
11 3322 44 55
11-- BaseBase 22-- AcuteAcute 33-- ChronicChronic 44-- PlicationPlication 55-- RecoveryRecovery
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
Change inChange in tetheringtethering distance (mm)distance (mm)
MR
MR
stro
kest
roke
volu
me
(mL/
beat
)vo
lum
e (m
L/be
at)
00
55
1010
1515
00 55 1010 1515 2020
BaseBase
AcuteAcute MIMI
ChronicChronic MIMI
Acute plicationAcute plication
Chronic plicationChronic plication
LienLien--Cohen et al., Cohen et al., Circulation Circulation 2000;101:27562000;101:2756
Treatment of ischemic MR: Infarct plicationTreatment of ischemic MR: Infarct plication
Ischemic Mitral RegurgitationIschemic Mitral Regurgitation
Type I Type I -- IIIbIIIbIncomplete mitral leaflet closureIncomplete mitral leaflet closure
Mechanims of iMRMechanims of iMR
•• NormalNormal leafletsleaflets
•• Decreased closing forcesDecreased closing forces due to due to global (global (and regionaland regional) LV) LV dysfunctiondysfunction
•• Annular dilatationAnnular dilatation
•• Increased tethering forcesIncreased tethering forces::-- apicalapical displacementdisplacement of PMof PM-- increasedincreased tetheringtethering distance and distance and
tentingtenting areaarea-- systolic restriction of the posterior systolic restriction of the posterior
±± anterior leafletsanterior leaflets-- bending ofbending of mid anterior leafletmid anterior leaflet
((seagull signseagull sign))