Ischemic mitral regurgitation: Difference between revisions
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Ischemic Mitral Regurgitation can be due to : | Ischemic Mitral Regurgitation can be due to : | ||
* [[Papillary muscle]] rupture secondary to [[acute MI]]. | * [[Papillary muscle]] rupture secondary to [[acute MI]]. | ||
* Most often Ischemic Mitral Regurgitation is “functional” and due to | * Most often Ischemic Mitral Regurgitation is “functional” and due to “[[papillary muscle]] displacement” involving a left ventricular-wall motion abnormality as well as alteration in left ventricular geometry <ref name="pmid7759707">{{cite journal | author = Tenenbaum A, Leor J, Motro M, Hod H, Kaplinsky E, Rabinowitz B, Boyko V, Vered Z | title = Improved posterobasal segment function after thrombolysis is associated with decreased incidence of significant mitral regurgitation in a first inferior myocardial infarction | journal = [[Journal of the American College of Cardiology]] | volume = 25 | issue = 7 | pages = 1558–63 | year = 1995 | month = June | pmid = 7759707 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/0735-1097(95)00041-2 | accessdate = 2011-02-20}}</ref>. | ||
==Epidemiology== | ==Epidemiology== | ||
| Line 21: | Line 21: | ||
<ref name="pmid15655133">{{cite journal | author = Bursi F, Enriquez-Sarano M, Nkomo VT, Jacobsen SJ, Weston SA, Meverden RA, Roger VL | title = Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation | journal = [[Circulation]] | volume = 111 | issue = 3 | pages = 295–301 | year = 2005 | month = January | pmid = 15655133 | doi = 10.1161/01.CIR.0000151097.30779.04 | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15655133 | accessdate = 2011-02-20}}</ref>. | <ref name="pmid15655133">{{cite journal | author = Bursi F, Enriquez-Sarano M, Nkomo VT, Jacobsen SJ, Weston SA, Meverden RA, Roger VL | title = Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation | journal = [[Circulation]] | volume = 111 | issue = 3 | pages = 295–301 | year = 2005 | month = January | pmid = 15655133 | doi = 10.1161/01.CIR.0000151097.30779.04 | url = http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15655133 | accessdate = 2011-02-20}}</ref>. | ||
==Diagnosis== | ==Diagnosis== | ||
===Symptoms=== | ===Symptoms=== | ||
The clinical presentation of Ischemic mitral regurgitation reflects the state of | The clinical presentation of Ischemic mitral regurgitation reflects the state of [[LV dysfunction]] more than the state of [[mitral valve]]. | ||
* Asymptomatic detected by Echocardiography or Angiography | * Asymptomatic detected by Echocardiography or Angiography | ||
| Line 43: | Line 42: | ||
* Exercise induced ERO ≥13 mm2 is an independent predictor of cardiac death. | * Exercise induced ERO ≥13 mm2 is an independent predictor of cardiac death. | ||
*<youtube v=ue2oCXo6Qik/> | * 3D ECHO can be helpful in differentiating ischemic mitral regurgitation from functional [[MR]] secondary to ventricular dilatation. The valvular abnormality is asymmetric in ischemic mitral regurgitation and symmetric in functional [[MR]]. | ||
<youtube v=ue2oCXo6Qik/> DOPPLER ECHOCARDIOGRAPHY | |||
==Treatment== | ==Treatment== | ||
Revision as of 04:29, 22 February 2011
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Overview
Ischemic mitral regurgitation can occur as a complication of either ST elevation myocardial infarction (MI) and acute myocardial ischemia. If mitral regurgitation occurs as a complication of MI it is permanent while if it occurs as a result of ischemia, it is transient and resolves with resolution of ischemia.
Pathophysiology
Papillary muscle normally exert a perpendicular force on leaflets thereby achieving optimal coaptation. With distortion of left ventricular geometry and displacement of papillary muscle, the tethering forces are exerted at an oblique angle resulting in insufficient coaptation.
Ischemic Mitral Regurgitation can be due to :
- Papillary muscle rupture secondary to acute MI.
- Most often Ischemic Mitral Regurgitation is “functional” and due to “papillary muscle displacement” involving a left ventricular-wall motion abnormality as well as alteration in left ventricular geometry [1].
Epidemiology
A higher incidence is observed in elderly and women [2] [3].
Diagnosis
Symptoms
The clinical presentation of Ischemic mitral regurgitation reflects the state of LV dysfunction more than the state of mitral valve.
Signs
- Approximately one half have holosystolic murmur
- Decreased cardiac output
- Exercise produces severe regurgitation in patients with mild ischemic mitral regurgitation.
- Severe cases present with pulmonary edema
Exercise Echocardiography
- Effective regurgitant orifice (ERO) area increase with exercise is associated with increased risk for acute pulmonary edema
- Exercise induced ERO ≥13 mm2 is an independent predictor of cardiac death.
- 3D ECHO can be helpful in differentiating ischemic mitral regurgitation from functional MR secondary to ventricular dilatation. The valvular abnormality is asymmetric in ischemic mitral regurgitation and symmetric in functional MR.
<youtube v=ue2oCXo6Qik/> DOPPLER ECHOCARDIOGRAPHY
Treatment
Treatment varies depending on the severity of ischemic mitral regurgitation with reperfusion in acute MI or heart transplantation.
- Ischemic mitral regurgitation associated with reduced left ventricular ejection fraction (LVEF) should be treated by reducing the after load with angiotensin converting enzyme inhibitors and/or angiotensin II receptor blockers, and beta blockers.
- Ischemic mitral regurgitation with normal mitral leaflets but abnormal left ventricular function and geometry can be treated by percutaneous revascularization which decreases ventricular remodeling & hence prevents MR[4] [5] [6].
- Acute ischemic mitral regurgitation is managed with intra-aortic balloon pump & medical therapy.
- Revascularization is less rewarding in chronic ischemic mitral regurgitation [7] [8].
- Ischemic mitral regurgitation due to papillary muscle rupture : Emergent mitral valve repair (which can be done only when there is no papillary muscle necrosis) despite a high operative mortality (20-25%)[9] [10] [11].
- Surgical approach for ischemic mitral regurgitation : The decision for valve surgery should be made prior to CABG as it increases the likelihood of air embolism, prolongs cardiopulmonary bypass time and thereby increasing operative mortality [12].
- Standard Surgical ring annuloplasty
- Restrictive annuloplasty
- Edge-to-edge leaflet repair
- Chordal manipulation eliminates tethering and restores normal leaflet coaptation [13] [14] [15].
- Modifying papillary muscle geometry
- Segmental ventricular constraints
- Biventricular pacing decreases tardiness of the posterior papillary muscle bearing segment & hence reduces tethering.
In ring annuloplasty antero-posterior annular dimension is reduced to restore coaptation. However, if the annular size alone is reduced, it persistently leaves the tethering to the displaced left ventricular wall and thereby causing recurrent MR[16].
Currently for ischemic mitral valve repair double orifice technique (edge-to-edge repair) along with ring annuloplasty is used to facilitate leaflet coaptation [17].
There is a mixed opinion regarding the outcome of mitral valve repair versus mitral valve replacement in patients with ischemic mitral valve with some investigators reporting mitral valve repair to be associated with better outcome [18] [19] [20].
Transvenous catheter-delivered annuloplasty device is an investigational alternative [21].
Posterior suture annuloplasty for Ischemic mitral regurgitation :
<youtube v=vWUos-0WM5w/>
- Cardiac Transplantation is an option in patient with severe ischemic mitral regurgitation and left ventricular dysfunction due to improved prognosis in comparison with valvular surgery but is contraindicated in elderly.
Prognosis
Acute ischemic mitral regurgitation is often associated with anterior wall infarction and wall motion abnormality leading to increased left ventricular volumes and subsequent heart failure [22] [3].
Independent of left ventricular function, MR is associated with higher mortality [23].
References
- ↑ Tenenbaum A, Leor J, Motro M, Hod H, Kaplinsky E, Rabinowitz B, Boyko V, Vered Z (1995). "Improved posterobasal segment function after thrombolysis is associated with decreased incidence of significant mitral regurgitation in a first inferior myocardial infarction". Journal of the American College of Cardiology. 25 (7): 1558–63. PMID 7759707. Retrieved 2011-02-20. Unknown parameter
|month=ignored (help) - ↑ Pellizzon GG, Grines CL, Cox DA, Stuckey T, Tcheng JE, Garcia E, Guagliumi G, Turco M, Lansky AJ, Griffin JJ, Cohen DJ, Aymong E, Mehran R, O'Neill WW, Stone GW (2004). "Importance of mitral regurgitation inpatients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial". Journal of the American College of Cardiology. 43 (8): 1368–74. doi:10.1016/j.jacc.2003.11.046. PMID 15093869. Retrieved 2011-02-20. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 Bursi F, Enriquez-Sarano M, Nkomo VT, Jacobsen SJ, Weston SA, Meverden RA, Roger VL (2005). "Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation". Circulation. 111 (3): 295–301. doi:10.1161/01.CIR.0000151097.30779.04. PMID 15655133. Retrieved 2011-02-20. Unknown parameter
|month=ignored (help) - ↑ Duarte IG, Shen Y, MacDonald MJ, Jones EL, Craver JM, Guyton RA (1999). "Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results". The Annals of Thoracic Surgery. 68 (2): 426–30. PMID 10475407. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Tolis GA, Korkolis DP, Kopf GS, Elefteriades JA (2002). "Revascularization alone (without mitral valve repair) suffices in patients with advanced ischemic cardiomyopathy and mild-to-moderate mitral regurgitation". The Annals of Thoracic Surgery. 74 (5): 1476–80, discussion 1480–1. PMID 12440595. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Gorman RC, Gorman JH (2006). "Why should we repair ischemic mitral regurgitation?". The Annals of Thoracic Surgery. 81 (2): 785, author reply 785–6. doi:10.1016/j.athoracsur.2005.07.028. PMID 16427907. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Diodato MD, Moon MR, Pasque MK, Barner HB, Moazami N, Lawton JS, Bailey MS, Guthrie TJ, Meyers BF, Damiano RJ (2004). "Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis". The Annals of Thoracic Surgery. 78 (3): 794–9, discussion 794–9. doi:10.1016/j.athoracsur.2004.03.022. PMID 15336993. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Penicka M, Linkova H, Lang O, Fojt R, Kocka V, Vanderheyden M, Bartunek J (2009). "Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery". Circulation. 120 (15): 1474–81. doi:10.1161/CIRCULATIONAHA.108.842104. PMID 19786637. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Kishon Y, Oh JK, Schaff HV, Mullany CJ, Tajik AJ, Gersh BJ (1992). "Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients". Mayo Clinic Proceedings. Mayo Clinic. 67 (11): 1023–30. PMID 1434862. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Lavie CJ, Gersh BJ (1990). "Mechanical and electrical complications of acute myocardial infarction". Mayo Clinic Proceedings. Mayo Clinic. 65 (5): 709–30. PMID 2190052. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ David TE (1994). "Techniques and results of mitral valve repair for ischemic mitral regurgitation". Journal of Cardiac Surgery. 9 (2 Suppl): 274–7. PMID 8186580. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Edwards FH, Peterson ED, Coombs LP, DeLong ER, Jamieson WR, Shroyer ALW, Grover FL (2001). "Prediction of operative mortality after valve replacement surgery". Journal of the American College of Cardiology. 37 (3): 885–92. PMID 11693766. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Levine RA, Schwammenthal E (2005). "Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts". Circulation. 112 (5): 745–58. doi:10.1161/CIRCULATIONAHA.104.486720. PMID 16061756. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Borger MA, Murphy PM, Alam A, Fazel S, Maganti M, Armstrong S, Rao V, David TE (2007). "Initial results of the chordal-cutting operation for ischemic mitral regurgitation". The Journal of Thoracic and Cardiovascular Surgery. 133 (6): 1483–92. doi:10.1016/j.jtcvs.2007.01.064. PMID 17532944. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ de Varennes B, Chaturvedi R, Sidhu S, Côté AV, Shan WL, Goyer C, Hatzakorzian R, Buithieu J, Sniderman A (2009). "Initial results of posterior leaflet extension for severe type IIIb ischemic mitral regurgitation". Circulation. 119 (21): 2837–43. doi:10.1161/CIRCULATIONAHA.108.831412. PMID 19451349. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Hung J, Papakostas L, Tahta SA, Hardy BG, Bollen BA, Duran CM, Levine RA (2004). "Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target". Circulation. 110 (11 Suppl 1): II85–90. doi:10.1161/01.CIR.0000138192.65015.45. PMID 15364844. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Nielsen SL, Timek TA, Lai DT, Daughters GT, Liang D, Hasenkam JM, Ingels NB, Miller DC (2001). "Edge-to-edge mitral repair: tension on the approximating suture and leaflet deformation during acute ischemic mitral regurgitation in the ovine heart". Circulation. 104 (12 Suppl 1): I29–35. PMID 11568026. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Oury JH, Cleveland JC, Duran CG, Angell WW (1994). "Ischemic mitral valve disease: classification and systemic approach to management". Journal of Cardiac Surgery. 9 (2 Suppl): 262–73. PMID 8186579. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Rankin JS, Feneley MP, Hickey MS, Muhlbaier LH, Wechsler AS, Floyd RD, Reves JG, Skelton TN, Califf RM, Lowe JE (1988). "A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation". The Journal of Thoracic and Cardiovascular Surgery. 95 (2): 165–77. PMID 3276968. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J, Lytle BW, McCarthy PM (2001). "Is repair preferable to replacement for ischemic mitral regurgitation?". The Journal of Thoracic and Cardiovascular Surgery. 122 (6): 1125–41. doi:10.1067/mtc.2001.116557. PMID 11726887. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Webb JG, Harnek J, Munt BI, Kimblad PO, Chandavimol M, Thompson CR, Mayo JR, Solem JO (2006). "Percutaneous transvenous mitral annuloplasty: initial human experience with device implantation in the coronary sinus". Circulation. 113 (6): 851–5. doi:10.1161/CIRCULATIONAHA.105.591602. PMID 16461812. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Aronson D, Goldsher N, Zukermann R, Kapeliovich M, Lessick J, Mutlak D, Dabbah S, Markiewicz W, Beyar R, Hammerman H, Reisner S, Agmon Y (2006). "Ischemic mitral regurgitation and risk of heart failure after myocardial infarction". Archives of Internal Medicine. 166 (21): 2362–8. doi:10.1001/archinte.166.21.2362. PMID 17130390. Retrieved 2011-02-21. Unknown parameter
|month=ignored (help) - ↑ Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ (2001). "Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment". Circulation. 103 (13): 1759–64. PMID 11282907. Retrieved 2011-02-20. Unknown parameter
|month=ignored (help)