Ischemic mitral regurgitation is the regurgitation seen with structurally normal valve leaflets that occurs in approximately 20% of patients after myocardial infarction and 56% of patients with congestive heart failure caused by ischemic or nonischemic cardiomyopathy. The initiating event is an ischemic insult that results in remodeling of the left ventricle toward a more spherical shape and new wall motion abnormalities. These changes lead to annular dilation and subvalvular distortion that prevent the mitral leaflets from coapting and closing completely during the contraction phase. Treatment options include coronary revascularization, ring annuloplasty, valve repair and replacement, or left ventricle reconstruction by way of localized reshaping or resection. Pharmacotherapy, aimed at raising left ventricular pressure without increasing tethering or left ventricular volume, is included in the treatment options for improving ischemic mitral regurgitation.
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References
1.
Birnbaum Y, Chamoun AJ, Conti VR, et al: Mitral regurgitation following acute myocardial infarction. Coron Artery Dis13:337-344,2002.
2.
Trichon BH, Felker GM, Shaw LK, et al: Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol91:538-543,2003.
3.
Filsoufi F, Salzberg SP, Adams DH: Current management of ischemic mitral regurgitation. Mt Sinai J Med72:105-115,2005.
4.
Lambert AS. Mitral regurgitation. In Perrino, AC, Reeves ST, editors: Practical Approach to Transesophageal Echocardiography. Philadelphia: Lippincott, Williams, & Wilkins; p 134-134,2003.
5.
Yoran C, Yellin EL, Becker RM, et al: Dynamic aspects of acute mitral regurgitation: Effects of ventricular volume, pressure and contractility on the effective regurgitant orifice area. Circulation60:170-176,1979.
6.
Yoran C, Yellin EL, Becker RM, et al: Mechanism of reduction of mitral regurgitation with vasodilator therapy. Am J Cardiol43:773-777,1979.
7.
Keren G, Bier A, Strom JA, et al: Dynamics of mitral regurgitation during nitroglycerin therapy: A Doppler echocardiographic study. Am Heart J112:517-525,1986.
8.
Schwammenthal E, Chen C, Benning F, et al: Dynamics of mitral regurgitant flow and orifice area. Physiologic application of the proximal flow convergence method: Clinical data and experimental testing. Circulation90:307-322,1994.
9.
Schwammenthal E, Levine RA: The non-ischemic dynamics of ischemic mitral regurgitation: Solving the paradox. Eur Heart J26:1454-1455,2005.
10.
He S, Fontaine AA, Schwammenthal E, et al: Integrated mechanism for functional mitral regurgitation: Leaflet restriction versus coapting force: In vitro studies. Circulation96:1826-1834,1997.
Wei JY, Hutchins GM, Bulkley BH: Papillary muscle rupture in fatal acute myocardial infarction: A potentially treatable form of cardiogenic shock. Ann Intern Med90:149-152,1979.
13.
Picard MH, Davidoff R, Sleeper LA, et al; SHOCK Trial: SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK. Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock. Circulation107:279-284,2003.
14.
Leor J, Feinberg MS, Vered Z, et al: Effect of thrombolytic therapy on the evolution of significant mitral regurgitation in patients with a first inferior myocardial infarction. J Am Coll Cardiol21:1661-16661993.
McGee EC, Gillinov AM, Blackstone EH, et al: Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg128:916-924,2004.
17.
Hung J, Papakostas L, Tahta SA, et al: Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: Continued LV remodeling as a moving target. Circulation110(11 Suppl 1):II85-90,2004.
18.
Yun KL, Sintek CF, Miller DC, et al: Randomized trial comparing partial versus complete chordal-sparing mitral valve replacement: Effects on left ventricular volume and function. J Thorac Cardiovasc Surg123:707-714,2002.
19.
Defraigne JO, Lavigne JP, Remy D, et al: [Mitral valve replacement in post-infarction rupture of the papillary muscle. Apropos of 13 cases surgically treated during the acute phase of infarction]Arch Mal Coeur Vaiss83:377-382,1990.
20.
Tavakoli R, Weber A,Vogt P, et al: Surgical management of acute mitral valve regurgitation due to post-infarction papillary muscle rupture. J Heart Valve Dis11:20-25; discussion 26,2002.
21.
Kaza AK, Patel MR, Fiser SM, et al: Ventricular reconstruction results in improved left ventricular function and amelioration of mitral insufficiency. Ann Surg235:828-832,2002.
22.
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. Circulation101:2756-2763,2000.
23.
Hung J, Guerrero JL, Handschumacher MD, et al: Reverse ventricular remodeling reduces ischemic mitral regurgitation: Echo-guided device application in the beating heart. Circulation106:2594-2600,2002.
24.
Menicanti L, Di Donato M; RESTORE Group: Surgical ventricular reconstruction and mitral regurgitation: What have we learned from 10 years of experience?Semin Thorac Cardiovasc Surg13:496-503,2001.
25.
Messas E, Guerrero JL, Handschumacher MD, et al: Chordal cutting: A new therapeutic approach for ischemic mitral regurgitation. Circulation104:1958-1963,2001.
26.
Heinle SK, Tice FD, Kisslo J: Effect of dobutamine stress echocardiography on mitral regurgitation. J Am Coll Cardiol25:122-127,1995.
27.
Keren G, Bier A, Strom JA, et al: Dynamics of mitral regurgitation during nitroglycerin therapy: A Doppler echocardiographic study. Am Heart J112:517-525,1986.
28.
Levine AB, Muller C, Levine TB: Effects of high-dose lisinopril-isosorbide dinitrate on severe mitral regurgitation and heart failure remodeling. Am J Cardiol82:1299-1301, A10-A10,1998.
29.
Kanzaki H, Bazaz R, Schwartzman D, et al: A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: Insights from mechanical activation strain mapping. J Am Coll Cardiol44:1619-1625,2004.
30.
Breithardt OA, Sinha AM, Schwammenthal E, et al: Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure. J Am Coll Cardiol41:765-770, 2003. Erratum in: J Am Coll Cardiol 41:1852,2003.
