Ischemic Ischemic Mitral Regurgitation Mitral Regurgitation Jean- - - PowerPoint PPT Presentation

▶
ischemic ischemic mitral regurgitation mitral
SMART_READER_LITE
LIVE PREVIEW

Ischemic Ischemic Mitral Regurgitation Mitral Regurgitation Jean- - - PowerPoint PPT Presentation

Apr 16, 2023 365 likes •929 views

Ischemic Ischemic Mitral Regurgitation Mitral Regurgitation Jean- -Louis J. Vanoverschelde, MD, Louis J. Vanoverschelde, MD, PhD PhD Jean Universit catholique de catholique de Louvain Louvain Universit Brussels, , Belgium

slide-1
SLIDE 1

Jean Jean-

  • Louis J. Vanoverschelde, MD,

Louis J. Vanoverschelde, MD, PhD PhD

Ischemic Ischemic Mitral Regurgitation Mitral Regurgitation

Universit Université é catholique de catholique de Louvain Louvain Brussels Brussels, , Belgium Belgium

slide-2
SLIDE 2

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Definition Definition Ischemic mitral regurgitation is mitral regurgitation due to Ischemic mitral regurgitation is mitral regurgitation due to complications of coronary artery disease, in particular, myocard complications of coronary artery disease, in particular, myocardial ial infarction, and not the fortuitous association of coronary arter infarction, 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

  • r

mitral valve prolapse. mitral valve prolapse.

slide-3
SLIDE 3

Ischemic Mitral Regurgitation Ischemic 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 prognos regurgitaion is frequent and appears to carry an adverse prognosis. is.

  • In the chronic post

In 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.

slide-4
SLIDE 4

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Prognostic value of MR in ischemic heart disease Prognostic value of MR in ischemic heart disease

  • 303 patients (mean age 70

303 patients (mean age 70 ± ± 10 yrs) with a first Q 10 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 days 16 days

  • Previous surgery

Previous surgery

  • Papillary muscle rupture

Papillary muscle rupture

  • MR of organic origin

MR of organic origin

  • Significant AR

Significant AR

Grigioni et al., Grigioni et al., Circulation

  • Circulation. 2001;103:1759.

. 2001;103:1759.

slide-5
SLIDE 5

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

IMR IMR no IMR no IMR p value p value (n=194) (n=194) (n=109) (n=109) Age, y Age, y 71 71± ±11 11 70 70± ±9 9 0.20 0.20 Men Men 135 (70%) 135 (70%) 86 (79%) 86 (79%) 0.08 0.08 NYHA III NYHA III– –IV IV 92 (47%) 92 (47%) 38 (35%) 38 (35%) 0.034 0.034

  • A. Fib.
  • A. Fib.

30 (15%) 30 (15%) 5 (5%) 5 (5%) 0.004 0.004 SBP SBP 132 132± ±26 26 141 141± ±26 26 0.004 0.004 Anterior MI Anterior MI 40 (21%) 40 (21%) 44 (40%) 44 (40%) 0.001 0.001 EF, % EF, % 33 33± ±14 14 34 34± ±11 11 0.14 0.14 LVS, mm/m LVS, mm/m² ² 28 28± ±6 6 26 26± ±6 6 0.003 0.003 LVD, mm/m LVD, mm/m² ² 33 33± ±5 5 31 31± ±5 5 0.001 0.001

Grigioni et al., Grigioni et al., Circulation

  • Circulation. 2001;103:1759.

. 2001;103:1759.

Prognostic value of MR in ischemic heart disease Prognostic value of MR in ischemic heart disease

slide-6
SLIDE 6

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Time ( Time (months months) ) Survival Survival (%) (%)

12 12 24 24 36 36 48 48 60 60 20 20 40 40 60 60 80 80 100 100 61 61± ±6% 6% 38 38± ±5% 5% MI MI without without MR MR MI MI with with MR MR P<0.001 P<0.001

Prognostic Prognostic value value of

  • f MR in

MR in ischemic ischemic heart heart disease disease

Grigioni et al., Grigioni et al., Circulation

  • Circulation. 2001;103:1759.

. 2001;103:1759.

slide-7
SLIDE 7

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

RR RR 95% CI 95% CI p value p value Age Age 1.03 1.03 1.01 1.01-

  • 1.05

1.05 < 0.001 < 0.001 EF EF 0.98 0.98 0.97 0.97-

  • 1.00

1.00 0.030 0.030 NYHA III NYHA III-

  • IV

IV 1.88 1.88 1.27 1.27-

  • 2.79

2.79 0.002 0.002 Diabetes Diabetes 1.48 1.48 0.99 0.99-

  • 2.20

2.20 0.054 0.054

  • A. Fib.
  • A. Fib.

1.62 1.62 1.00 1.00-

  • 2.62

2.62 0.049 0.049 1/Creatinine 1/Creatinine 0.44 0.44 0.21 0.21-

  • 0.94

0.94 0.034 0.034

  • R. Vol. < 30 mL
  • R. Vol. < 30 mL

1.64 1.64 0.98 0.98-

  • 2.75

2.75 0.059 0.059

  • R. Vol.
  • R. Vol. ≥

≥ 30 mL 30 mL 2.05 2.05 1.30 1.30-

  • 3.23

3.23 0.002 0.002 Multivariate predictors of overall survival Multivariate predictors of overall survival

Grigioni et al., Grigioni et al., Circulation

  • Circulation. 2001;103:1759.

. 2001;103:1759.

slide-8
SLIDE 8

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation ERO > 20 mm ERO > 20 mm2

2

and and/or /or RV > 30 mL RV > 30 mL adjusted adjusted RR: 2.01 RR: 2.01 -

  • 2.38

2.38

Prognostic Prognostic value value of

  • f MR in

MR in ischemic ischemic heart heart disease disease

Grigioni et al., Grigioni et al., Circulation

  • Circulation. 2001;103:1759.

. 2001;103:1759.

slide-9
SLIDE 9

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Prognostic Prognostic value value of

  • f MR in

MR in ischemic ischemic heart heart disease disease

Grigioni et al., Grigioni et al., Circulation

  • Circulation. 2001;103:1759.

. 2001;103:1759.

Time ( Time (months months) ) Survival Survival (%) (%)

12 12 24 24 36 36 48 48 60 60 20 20 40 40 60 60 80 80 100 100 61 61± ±6% 6% 36 36± ±7% 7% RVol RVol

1 1-

  • 29

29 > 30 > 30

P < 0.0001 P < 0.0001 44 44± ±9% 9%

slide-10
SLIDE 10

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Prognostic Prognostic value value of

  • f MR in

MR in ischemic ischemic heart heart disease disease

Grigioni et al., Grigioni et al., Circulation

  • Circulation. 2001;103:1759.

. 2001;103:1759.

Time ( Time (months months) ) Survival Survival (%) (%)

12 12 24 24 36 36 48 48 60 60 20 20 40 40 60 60 80 80 100 100 61 61± ±6% 6% 29 29± ±9% 9% ERO ERO

1 1-

  • 19

19 > 20 > 20

P < 0.0001 P < 0.0001 47 47± ±8% 8%

slide-11
SLIDE 11

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Time (years) Time (years) Incidence of CHF (%) Incidence of CHF (%)

1 1 2 2 3 3 4 4 6 6 20 20 40 40 60 60 80 80 100 100 53 53± ±7% 7% 18 18± ±5% 5% MI MI without without MR MR MI MI with with MR MR P<0.001 P<0.001

Impact of iMR Impact of iMR on the development of heart failure

  • n the development of heart failure

Grigioni et al., Grigioni et al., J Am Coll Cardiol J Am Coll Cardiol. 2005;45:260. . 2005;45:260.

5 5

slide-12
SLIDE 12

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Time (years) Time (years) Incidence of CHF (%) Incidence of CHF (%)

1 1 2 2 3 3 4 4 6 6 20 20 40 40 60 60 80 80 100 100 18 18± ±5% 5% P<0.001 P<0.001

Impact of iMR Impact of iMR on the development of heart failure

  • n the development of heart failure

Grigioni et al., Grigioni et al., J Am Coll Cardiol J Am Coll Cardiol. 2005;45:260. . 2005;45:260.

5 5 ERO ERO

1 1-

  • 19

19 > 20 > 20

46 46± ±9% 9% 68 68± ±12% 12%

slide-13
SLIDE 13

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Type Type I I annular annular dilatation dilatation

Ischemic mitral Ischemic mitral regurgitation: Type I dysfunction regurgitation: Type I dysfunction

slide-14
SLIDE 14

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic mitral Ischemic mitral regurgitation: Type II dysfunction regurgitation: Type II dysfunction

Type II Type II Papillary muscle Papillary muscle rupture rupture

slide-15
SLIDE 15

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic mitral Ischemic mitral regurgitation: Type II dysfunction regurgitation: Type II dysfunction

Type II Type II Papillary muscle Papillary muscle elongation elongation

slide-16
SLIDE 16

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Type IIIb Type IIIb Leaflet Leaflet restriction restriction

Ischemic mitral Ischemic mitral regurgitation: Type III dysfunction regurgitation: Type III dysfunction

slide-17
SLIDE 17

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • Incomplete leaflet

Incomplete leaflet and scallop coaptation and scallop coaptation

  • Decreased closing forces

Decreased closing forces

  • Annular dilatation and loss of annular contraction

Annular dilatation and loss of annular contraction

  • Increased tethering forces

Increased tethering forces Ischemic Ischemic mitral mitral regurgitation: Decreased closing forces regurgitation: Decreased closing forces

slide-18
SLIDE 18

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • Incomplete leaflet

Incomplete leaflet and scallop coaptation and scallop coaptation

  • Decreased closing forces

Decreased closing forces

  • Annular dilatation and loss of annular contraction

Annular dilatation and loss of annular contraction

  • Increased tethering forces

Increased tethering forces Ischemic Ischemic mitral mitral regurgitation: Decreased closing forces regurgitation: Decreased closing forces

slide-19
SLIDE 19

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic mitral regurgitation: Ischemic mitral regurgitation: Decreased closing forces Decreased closing forces

10 10 6 6 4 4 2 2 8 8 +1 +1 +2 +2 +3 +3 +4 +4 1600 1600 1200 1200 800 800 400 400 +1 +1 +2 +2 +3 +3 +4 +4

Degree Degree of MR

  • f MR

Degree Degree of MR

  • f MR

Coaptation distance (cm) Coaptation distance (cm) LV LV dP dP/ /dt dt ( (mmHg mmHg/s) /s)

r=0.99 r=0.99 P<0.0001 P<0.0001 r= r=-

  • 0.94

0.94 P<0.0001 P<0.0001

Kaul Kaul et al., et al., Circulation Circulation 1991;84:2167 1991;84:2167

slide-20
SLIDE 20

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • Incomplete leaflet

Incomplete leaflet and scallop coaptation and scallop coaptation

  • Decreased closing forces

Decreased closing forces

  • Annular dilatation and loss of annular contraction

Annular dilatation and loss of annular contraction

  • Increased tethering forces

Increased tethering forces Ischemic Ischemic mitral mitral regurgitation: Annular dilatation regurgitation: Annular dilatation

slide-21
SLIDE 21

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic Ischemic mitral regurgitation: Annular dilatation mitral regurgitation: Annular dilatation

Timek Timek et al., et al., Circulation Circulation 2002;106 (suppl I):I 2002;106 (suppl I):I-

  • 33

33

slide-22
SLIDE 22

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • 400

400

  • 300

300

  • 200

200

  • 100

100 100 100 200 200 300 300 400 400

11.2 11.2 10.8 10.8 10.4 10.4 10.0 10.0 9.8 9.8

Time (ms) Time (ms) Annular perimeter (cm) Annular perimeter (cm) Ischemic mitral regurgitation: Annular dilatation Ischemic mitral regurgitation: Annular dilatation

Timek Timek et al., et al., Circulation Circulation 2002;106 (suppl I):I 2002;106 (suppl I):I-

  • 33

33

baseline baseline ischemia ischemia

slide-23
SLIDE 23

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic mitral Ischemic mitral regurgitation: Posterior commissure involvement regurgitation: Posterior commissure involvement

AC AC P1 P1 P2 P2 P3 P3 PC PC A1 A1 A2 A2 A3 A3

P3 P3

Normal Normal Ischemic Ischemic

slide-24
SLIDE 24

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic mitral Ischemic mitral regurgitation: Posterior commissure involvement regurgitation: Posterior commissure involvement

P3 P3

Ischemic Ischemic

slide-25
SLIDE 25

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

He and al. He and al. J Heart Valve Dis J Heart Valve Dis 1999;8:294 1999;8:294

Annulus Annulus size (times normal) size (times normal) MR volume (mL) MR volume (mL)

5 5 10 10 15 15 20 20 25 25 30 30

Ischemic mitral regurgitation: Annular dilatation Ischemic mitral regurgitation: Annular dilatation

0.8 0.8 1.0 1.0 1.2 1.2 1.4 1.4 1.6 1.6 2.0 2.0 2.2 2.2 1.8 1.8

Normal PM position Normal PM position Symmetrical PM tethering Symmetrical PM tethering Anterior PM tethering Anterior PM tethering Posterior PM tethering Posterior PM tethering

slide-26
SLIDE 26

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • Incomplete leaflet

Incomplete leaflet and scallop coaptation and scallop coaptation

  • Decreased closing forces

Decreased closing forces

  • Annular dilatation and loss of annular contraction

Annular dilatation and loss of annular contraction

  • Increased tethering forces

Increased tethering forces Ischemic Ischemic mitral mitral regurgitation: Increased tenting regurgitation: Increased tenting

slide-27
SLIDE 27

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Yiu Yiu et al., et al., Circulation Circulation 2000;102:1400 2000;102:1400

Ischemic mitral regurgitation: Increased tenting Ischemic mitral regurgitation: Increased tenting Tenting area Tenting area

slide-28
SLIDE 28

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Yiu Yiu et al., et al., Circulation Circulation 2000;102:1400 2000;102:1400

3 3 8 8 7 7 6 6 5 5 4 4 9 9 13 13 11 11 10 10 12 12 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 25 25 20 20 15 15 10 10 5 5 30 30 40 40 35 35 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10

ERO (mm ERO (mm2

2)

) Tenting area Tenting area (cm (cm2

2)

) Annular Annular contraction (%) contraction (%)

r=0.74 r=0.74 p<0.0001 p<0.0001 r= r=-

  • 0.61

0.61 p<0.0001 p<0.0001

Ischemic mitral regurgitation: Increased tenting Ischemic mitral regurgitation: Increased tenting

slide-29
SLIDE 29

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Yiu Yiu et al., et al., Circulation Circulation 2000;102:1400 2000;102:1400

4 4 9 9 8 8 7 7 6 6 5 5 10 10 3 3 13 13 12 12 11 11 10 10 9 9 8 8 7 7 6 6 5 5 4 4

Tenting area Tenting area (cm (cm2

2)

) PPM PPM -

  • fibrosa

fibrosa distance (mm) distance (mm)

r=0.75 r=0.75 p<0.0001 p<0.0001

Ischemic mitral regurgitation: Increased tenting Ischemic mitral regurgitation: Increased tenting

slide-30
SLIDE 30

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic mitral regurgitation: Asymmetrical vs symmetrical tenti Ischemic mitral regurgitation: Asymmetrical vs symmetrical tenting ng

Agricola Agricola et al., et al., Eur J Echocardiogr Eur J Echocardiogr 200 2004 4; ;5 5: :326 326

slide-31
SLIDE 31

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic mitral regurgitation: Asymmetrical vs symmetrical tenti Ischemic mitral regurgitation: Asymmetrical vs symmetrical tenting ng

Agricola Agricola et al., et al., Eur J Echocardiogr Eur J Echocardiogr 200 2004 4; ;5 5: :326 326

slide-32
SLIDE 32

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic Ischemic mitral mitral regurgitation regurgitation: : Asymmetrical Asymmetrical tenting tenting -

  • the

the seagull seagull sign sign

slide-33
SLIDE 33

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Ischemic mitral regurgitation: Asymmetrical tenting Ischemic mitral regurgitation: Asymmetrical tenting -

  • the seagull sign

the seagull sign

slide-34
SLIDE 34

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

rest rest exercise exercise Pt #1 Pt #1 Pt #2 Pt #2 Pt #3 Pt #3 Exercise Exercise-

  • induced changes in MR severity in dilated cardiomyopathy

induced changes in MR severity in dilated cardiomyopathy

Lapu Lapu-

  • Bula

Bula et al., et al., Circulation Circulation 2002; 2002;106:1342 106:1342

slide-35
SLIDE 35

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Changes in Changes in stroke stroke volume (ml/beat) volume (ml/beat)

  • 30

30 -

  • 25

25 -

  • 20

20 -

  • 15

15 -

  • 10

10 -

  • 5

5 5 5 10 10 15 15 20 20 25 25 30 30 35 35 40 40 45 45 50 50

% changes in % changes in mitral mitral regurgitation regurgitation

5 5 10 10 15 15 20 20 25 25 30 30 35 35 40 40 N=25 N=25 r= r=-

  • 0.87

0.87

Exercise Exercise-

  • induced changes in MR severity in dilated cardiomyopathy

induced changes in MR severity in dilated cardiomyopathy

Lapu Lapu-

  • Bula

Bula et al., et al., Circulation Circulation 2002; 2002;106:1342 106:1342

slide-36
SLIDE 36

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Impact of exercise Impact of exercise-

  • induced mitral regurgitation on exercise tolerance

induced mitral regurgitation on exercise tolerance

Lapu Lapu-

  • Bula

Bula et al., et al., Circulation Circulation 2002; 2002;106:1342 106:1342

Changes in pulmonary wedge pressure (mmHg) Changes in pulmonary wedge pressure (mmHg)

10 10 20 20 30 30 40 40 50 50 N = 25 N = 25 r = 0.62 r = 0.62

% changes in % changes in mitral mitral regurgitation regurgitation

5 5 10 10 15 15 20 20 25 25 30 30 35 35 40 40

slide-37
SLIDE 37

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Impact of exercise Impact of exercise-

  • induced mitral regurgitation on exercise tolerance

induced mitral regurgitation on exercise tolerance

Lapu Lapu-

  • Bula

Bula et al., et al., Circulation Circulation 2002; 2002;106:1342 106:1342

% changes in % changes in mitral mitral regurgitation regurgitation

5 5 10 10 15 15 20 20 25 25 30 30 35 35 40 40 4 4 6 6 8 8 10 10 12 12 14 14 16 16 18 18 20 20 22 22 N = 25 N = 25 r = r = -

  • 0.67

0.67

VO VO2

2 max (mL/kg/min)

max (mL/kg/min)

slide-38
SLIDE 38

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Lapu Lapu-

  • Bula

Bula et al., et al., Circulation Circulation 2002; 2002;106:1342 106:1342

Exercise MR (%) Exercise MR (%) Exercise Exercise coaptation coaptation distance distance (cm) (cm)

5 5 10 10 15 15 20 20 25 25 30 30 35 35 40 40 10 10 20 20 30 30 40 40 50 50 60 60 70 70 80 80

% changes in MR severity % changes in MR severity % changes in % changes in coaptation coaptation distance distance

20 20 40 40 60 60 80 80 5 5 10 10 15 15 20 20 25 25 30 30 35 35 40 40 r=0.86 r=0.86 p<0.001 p<0.001 r=0.81 r=0.81 p<0.001 p<0.001

Exercise Exercise-

  • induced changes in MR severity in dilated cardiomyopathy

induced changes in MR severity in dilated cardiomyopathy

slide-39
SLIDE 39

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Time ( Time (months months) ) Survival Survival (%) (%)

12 12 18 18 24 24 30 30 36 36 20 20 40 40 60 60 80 80 100 100 ∆ ∆ ERO < 13 mm ERO < 13 mm² ² ∆ ∆ ERO ERO ≥ ≥ 13 mm 13 mm² ² P<0.0011 P<0.0011

Prognostic Prognostic value value of

  • f MR in

MR in ischemic ischemic heart heart disease disease

Lancellotti et al., Lancellotti et al., Circulation Circulation 2003;108:1713. 2003;108:1713.

6 6

slide-40
SLIDE 40

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • Restore leaflet

Restore leaflet and scallop coaptation and scallop coaptation

  • Improve closing forces

Improve closing forces

  • Reduce annular size

Reduce annular size

  • Decrease tethering forces

Decrease tethering forces Treatment of ischemic Treatment of ischemic mitral mitral regurgitation regurgitation

slide-41
SLIDE 41

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • Restore leaflet

Restore leaflet and scallop coaptation and scallop coaptation

  • Improve closing forces

Improve closing forces

  • Reduce annular size

Reduce annular size

  • Decrease tethering forces

Decrease tethering forces Treatment of ischemic Treatment of ischemic mitral mitral regurgitation regurgitation

slide-42
SLIDE 42

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Aklog Aklog et al., et al., Circulation Circulation 2001;104:I68 2001;104:I68

Treatment of ischemic MR: Role of Treatment of ischemic MR: Role of CABG CABG

% of patients % of patients

2+ 2+ 1+ 1+ 3+ 3+ 4+ 4+ Intra Intra-

  • op
  • p TEE

TEE 60 60 30 30 20 20 10 10 50 50 40 40

29% 29% 53% 53% 8% 8% 11% 11%

% of patients % of patients

2+ 2+ 1+ 1+ 3+ 3+ 4+ 4+ Post Post-

  • op
  • p TEE

TEE 60 60 30 30 20 20 10 10 50 50 40 40

4% 4% 51% 51% 4% 4% 37% 37% 3% 3%

slide-43
SLIDE 43

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • Restore leaflet

Restore leaflet and scallop coaptation and scallop coaptation

  • Improve closing forces

Improve closing forces

  • Reduce annular size

Reduce annular size

  • Decrease tethering forces

Decrease tethering forces Treatment of ischemic Treatment of ischemic mitral mitral regurgitation regurgitation

slide-44
SLIDE 44

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Hung Hung et al., et al., Circulation Circulation 2004 2004; ;110 110: :II II-

  • 85

85

Restrictive annuloplasty does not prevent recurrence of ischemic Restrictive annuloplasty does not prevent recurrence of ischemic MR MR Vena contracta (cm) Vena contracta (cm)

Early post Early post-

  • op
  • p

LVESD = 58 mm LVESD = 58 mm Late post Late post-

  • op
  • p

LVESD = 73 mm LVESD = 73 mm Early Early post post-

  • op
  • p

Per Per-

  • op
  • p

Pre Pre-

  • op
  • p

Late Late post post-

  • op
  • p

0.0 0.0 1.0 1.0 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2

p=0.009 p=0.009

slide-45
SLIDE 45

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Guy Guy et al., et al., J Am Coll Cardiol J Am Coll Cardiol 2004 2004; ;43 43: :377 377

Late Late post post-

  • op
  • p

Early Early post post-

  • op
  • p

Pre Pre-

  • op
  • p

70 70 110 110 100 100 90 90 80 80

LVESV (mL) LVESV (mL) Restrictive annuloplasty does not prevent LV remodeling Restrictive annuloplasty does not prevent LV remodeling ES shericity index ES shericity index

0.25 0.25 0.45 0.45 0.40 0.40 0.35 0.35 0.30 0.30 Late Late post post-

  • op
  • p

Early Early post post-

  • op
  • p

Pre Pre-

  • op
  • p

p=0.02 p=0.02 p=0.03 p=0.03

slide-46
SLIDE 46

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

  • Restore leaflet

Restore leaflet and scallop coaptation and scallop coaptation

  • Improve closing forces

Improve closing forces

  • Reduce annular size

Reduce annular size

  • Decrease tethering forces

Decrease tethering forces Treatment of ischemic Treatment of ischemic mitral mitral regurgitation regurgitation

slide-47
SLIDE 47

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Treatment of ischemic MR: Secondary chordae cutting Treatment of ischemic MR: Secondary chordae cutting

Messas Messas et al., et al., Circulation Circulation 2001;104:1958 2001;104:1958

slide-48
SLIDE 48

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

baseline baseline inferior inferior ischemia ischemia inferior inferior + PM + PM chordae cutting chordae cutting

Treatment of ischemic MR: Secondary chordae cutting Treatment of ischemic MR: Secondary chordae cutting

Messas Messas et al., et al., Circulation Circulation 2001;104:1958 2001;104:1958

slide-49
SLIDE 49

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Messas Messas et al., et al., Circulation Circulation 2001;104:1958 2001;104:1958

Treatment of ischemic MR: Secondary chordae cutting Treatment of ischemic MR: Secondary chordae cutting Leaflet covering area Leaflet covering area (cm (cm2

2)

) MR MR stroke stroke volume (mL/beat) volume (mL/beat)

2 2 4 4 6 6 8 8 10 10 5.5 5.5 6 6 6.5 6.5 7 7 7.5 7.5 8 8 9 9 8.5 8.5

slide-50
SLIDE 50

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Anterior Anterior leaflet leaflet restriction: restriction: secondary secondary chords chords excision excision

slide-51
SLIDE 51

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

suture suture rows rows infarct infarct zone zone

Lien Lien-

  • Cohen et al.,

Cohen et al., Circulation Circulation 2000;101:2756 2000;101:2756

Treatment of ischemic MR: Infarct plication Treatment of ischemic MR: Infarct plication Plication Plication

slide-52
SLIDE 52

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Chronic Chronic MI MI Acute plication Acute plication Chronic plication Chronic plication

Lien Lien-

  • Cohen et al.,

Cohen et al., Circulation Circulation 2000;101:2756 2000;101:2756

Treatment of ischemic MR: Infarct plication Treatment of ischemic MR: Infarct plication

slide-53
SLIDE 53

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Lien Lien-

  • Cohen et al.,

Cohen et al., Circulation Circulation 2000;101:2756 2000;101:2756

Treatment of ischemic MR: Infarct plication Treatment of ischemic MR: Infarct plication

10 10 6 6 4 4 2 2 8 8

MR volume (mL/beat) MR volume (mL/beat)

1 1 3 3 2 2 4 4 5 5 16 16 8 8 4 4 12 12

Change in Change in tethering tethering distance (mm) distance (mm)

1 1 3 3 2 2 4 4 5 5 1 1-

  • Base

Base 2 2-

  • Acute

Acute 3 3-

  • Chronic

Chronic 4 4-

  • Plication

Plication 5 5-

  • Recovery

Recovery

slide-54
SLIDE 54

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Change in Change in tethering tethering distance (mm) distance (mm) MR MR stroke stroke volume (mL/beat) volume (mL/beat)

5 5 10 10 15 15 5 5 10 10 15 15 20 20

Base Base Acute Acute MI MI Chronic Chronic MI MI Acute plication Acute plication Chronic plication Chronic plication

Lien Lien-

  • Cohen et al.,

Cohen et al., Circulation Circulation 2000;101:2756 2000;101:2756

Treatment of ischemic MR: Infarct plication Treatment of ischemic MR: Infarct plication

slide-55
SLIDE 55

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation

Type I Type I -

  • IIIb

IIIb Incomplete mitral leaflet closure Incomplete mitral leaflet closure Mechanims of iMR Mechanims of iMR

  • Normal

Normal leaflets leaflets

  • Decreased closing forces

Decreased closing forces due to due to global ( global (and regional and regional) LV ) LV dysfunction dysfunction

  • Annular dilatation

Annular dilatation

  • Increased tethering forces

Increased tethering forces: :

  • apical

apical displacement displacement of PM

  • f PM
  • increased

increased tethering tethering distance and distance and tenting tenting area area

  • systolic restriction of the posterior

systolic restriction of the posterior ± ± anterior leaflets anterior leaflets

  • bending of

bending of mid anterior leaflet mid anterior leaflet ( (seagull sign seagull sign) )