Ischemic Mitral Regurgitation
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1 Ischemic Mitral Regurgitation Jean-Louis J. Vanoverschelde, MD, PhD Université catholique de Louvain Brussels, Belgium
2 Definition Ischemic mitral regurgitation is mitral regurgitation due to complications of coronary artery disease, in particular, myocardial infarction, and not the fortuitous association of coronary artery disease with intrinsic valve disease such as rheumatic disease, or mitral valve prolapse.
3 In the acute phase of myocardial infarction, ischemic mitral regurgitaion is frequent and appears to carry an adverse prognosis. In the chronic post-myocardial infarction phase, angiographic mitral regurgitaion is frequent (> 19% grade II MR) and is predictive of survival, even if mild to moderate in severity. For diagnosis purposes, murmur is of limited value. Objective methods are therefore required.
4 Prognostic value of MR in ischemic heart disease 303 patients (mean age 70 ± 10 yrs) with a first Q-wave Q MI older than 16 days before baseline assessment. Exclusion criteria : MI 16 days Previous surgery Papillary muscle rupture MR of organic origin Significant AR Grigioni et al., Circulation ;103:1759.
5 Prognostic value of MR in ischemic heart disease IMR (n=194) no IMR (n=109) p value Age, y 71± ± Men 135 (70%) 86 (79%) 0.08 NYHA III IV IV 92 (47%) 38 (35%) A. Fib. 30 (15%) 5 (5%) SBP 132± ± Anterior MI 40 (21%) 44 (40%) EF, % 33±14 34± LVS, mm/m² 28±6 26± LVD, mm/m² 33±5 31± Grigioni et al., Circulation ;103:1759.
6 Prognostic value of MR in ischemic heart disease MI without MR Survival (%) MI with MR 61±6% 6% 38±5% 20 0 P< Time (months( months) Grigioni et al., Circulation ;103:1759.
7 Multivariate predictors of overall survival RR 95% CI p value Age < EF NYHA III-IV IV Diabetes A. Fib /Creatinine R. Vol. < 30 ml R. Vol. 30 ml Grigioni et al., Circulation ;103:1759.
8 Prognostic value of MR in ischemic heart disease ERO > 20 mm 2 and/or RV > 30 ml adjusted RR: Grigioni et al., Circulation ;103:1759.
9 Prognostic value of MR in ischemic heart disease Survival (%) RVol > 30 P < ±6% 6% 44±9% 36±7% Time (months( months) Grigioni et al., Circulation ;103:1759.
10 Prognostic value of MR in ischemic heart disease Survival (%) ERO > 20 P < ±6% 6% 47±8% 29±9% 9% Time (months( months) Grigioni et al., Circulation ;103:1759.
11 Impact of imr on the development of heart failure Incidence of CHF (%) P<0.001 MI with MR Time (years) MI without MR 53±7% 18±5% Grigioni et al., J Am Coll Cardiol ;45:260.
12 Impact of imr on the development of heart failure 100 ERO P<0.001 Incidence of CHF (%) > 20 68±12% 46±9% 18±5% Time (years) Grigioni et al., J Am Coll Cardiol ;45:260.
13 Ischemic mitral regurgitation: Type I dysfunction Type I annular dilatation
14 Ischemic mitral regurgitation: Type II dysfunction Type II Papillary muscle rupture
15 Ischemic mitral regurgitation: Type II dysfunction Type II Papillary muscle elongation
16 Ischemic mitral regurgitation: Type III dysfunction Type IIIb Leaflet restriction
17 Ischemic mitral regurgitation: Decreased closing forces Incomplete leaflet and scallop coaptation - Decreased closing forces - Annular dilatation and loss of annular contraction - Increased tethering forces
18 Ischemic mitral regurgitation: Decreased closing forces Incomplete leaflet and scallop coaptation - Decreased closing forces - Annular dilatation and loss of annular contraction - Increased tethering forces
19 Ischemic mitral regurgitation: Decreased closing forces Coaptation distance (cm) r=0.99 P< LV dp/dt dt (mmhg mmhg/s) r=-0.94 P< Degree of MR Degree of MR Kaul et al., Circulation 1991;84:2167
20 Ischemic mitral regurgitation: Annular dilatation Incomplete leaflet and scallop coaptation - Decreased closing forces - Annular dilatation and loss of annular contraction - Increased tethering forces
21 Ischemic mitral regurgitation: Annular dilatation Timek et al., Circulation 2002;106 (suppl I):I-33
22 Ischemic mitral regurgitation: Annular dilatation Annular perimeter (cm) baseline ischemia Time (ms) Timek et al., Circulation 2002;106 (suppl I):I-33
23 Ischemic mitral regurgitation: Posterior commissure involvement AC P1 A1 P2 A2 A3 P3 PC P3 Normal Ischemic
24 Ischemic mitral regurgitation: Posterior commissure involvement P3 Ischemic
25 Ischemic mitral regurgitation: Annular dilatation Posterior PM tethering Anterior PM tethering MR volume (ml) Symmetrical PM tethering Normal PM position Annulus size (times normal) He and al. J Heart Valve Dis 1999;8:294
26 Ischemic mitral regurgitation: Increased tenting Incomplete leaflet and scallop coaptation - Decreased closing forces - Annular dilatation and loss of annular contraction - Increased tethering forces
27 Ischemic mitral regurgitation: Increased tenting Tenting area Yiu et al., Circulation 2000;102:1400
28 Ischemic mitral regurgitation: Increased tenting ERO (mm 2 ) r=0.74 p< Tenting area (cm 2 ) r=-0.61 p< Annular contraction (%) Yiu et al., Circulation 2000;102:1400
29 Ischemic mitral regurgitation: Increased tenting Tenting area (cm 2 ) r=0.75 p< PPM - fibrosa distance (mm) Yiu et al., Circulation 2000;102:1400
30 Ischemic mitral regurgitation: Asymmetrical vs symmetrical tenting ng Agricola et al., Eur J Echocardiogr 2004;5:326
31 Ischemic mitral regurgitation: Asymmetrical vs symmetrical tenting ng Agricola et al., Eur J Echocardiogr 2004;5:326
32 Ischemic mitral regurgitation: Asymmetrical tenting - the seagull sign
33 Ischemic mitral regurgitation: Asymmetrical tenting - the seagull sign
34 Exercise-induced induced changes in MR severity in dilated cardiomyopathy rest exercise Pt #1 Pt #2 Pt #3 Lapu-Bula et al., Circulation 2002;106:1342
35 Exercise-induced induced changes in MR severity in dilated cardiomyopathy % changes in mitral regurgitation N=25 r= Changes in stroke volume (ml/beat) Lapu-Bula et al., Circulation 2002;106:1342
36 Impact of exercise-induced induced mitral regurgitation on exercise tolerance % changes in mitral regurgitation N = 25 r = Changes in pulmonary wedge pressure (mmhg) Lapu-Bula et al., Circulation 2002;106:1342
37 Impact of exercise-induced induced mitral regurgitation on exercise tolerance % changes in mitral regurgitation N = 25 r = VO 2 max (ml/kg/min) Lapu-Bula et al., Circulation 2002;106:1342
38 Exercise-induced induced changes in MR severity in dilated cardiomyopathy Exercise MR (%) r=0.86 p<0.001 % changes in MR severity r=0.81 p< Exercise coaptation distance (cm) % changes in coaptation distance Lapu-Bula et al., Circulation 2002;106:1342
39 Prognostic value of MR in ischemic heart disease 100 ERO < 13 mm² 80 Survival (%) ERO 13 mm² 20 0 P< Time (months( months) Lancellotti et al., Circulation 2003;108:1713.
40 Treatment of ischemic mitral regurgitation Restore leaflet and scallop coaptation - Improve closing forces - Reduce annular size - Decrease tethering forces
41 Treatment of ischemic mitral regurgitation Restore leaflet and scallop coaptation - Improve closing forces - Reduce annular size - Decrease tethering forces
42 Treatment of ischemic MR: Role of CABG % 50 51% % of patients % % of patients % % 11% % 4% 3% Intra-op TEE Post-op op TEE Aklog et al., Circulation 2001;104:I68
43 Treatment of ischemic mitral regurgitation Restore leaflet and scallop coaptation - Improve closing forces - Reduce annular size - Decrease tethering forces
44 Restrictive annuloplasty does not prevent recurrence of ischemic MR 1.0 p=0.009 Vena contracta (cm) Early post-op op LVESD = 58 mm Late post-op op LVESD = 73 mm 0.0 Pre-op Per-op Early post-op op Late post-op op Hung et al., Circulation 2004; :II-85
45 Restrictive annuloplasty does not prevent LV remodeling 110 p= p=0.03 LVESV (ml) ES shericity index Pre-op Early post-op op Late post-op op 0.25 Pre-op Early post-op op Late post-op op Guy et al., J Am Coll Cardiol 2004;43 43:377377
46 Treatment of ischemic mitral regurgitation Restore leaflet and scallop coaptation - Improve closing forces - Reduce annular size - Decrease tethering forces
47 Treatment of ischemic MR: Secondary chordae cutting Messas et al., Circulation 2001;104:1958
48 Treatment of ischemic MR: Secondary chordae cutting baseline inferior ischemia inferior + PM chordae cutting Messas et al., Circulation 2001;104:1958
49 Treatment of ischemic MR: Secondary chordae cutting 10 MR stroke volume (ml/beat) Leaflet covering area (cm 2 ) Messas et al., Circulation 2001;104:1958
50 Anterior leaflet restriction: secondary chords excision
51 Treatment of ischemic MR: Infarct plication infarct zone Plication suture rows Lien-Cohen et al., Circulation 2000;101:2756
52 Treatment of ischemic MR: Infarct plication Chronic MI Acute plication Chronic plication Lien-Cohen et al., Circulation 2000;101:2756
53 Treatment of ischemic MR: Infarct plication MR volume (ml/beat) Change in tethering distance (mm) Base 2- Acute 3- Chronic 4- Plication 5- Recovery Lien-Cohen et al., Circulation 2000;101:2756
54 Treatment of ischemic MR: Infarct plication MR stroke volume (ml/beat) Base Acute MI Chronic MI Acute plication Chronic plication Change in tethering distance (mm) Lien-Cohen et al., Circulation 2000;101:2756
55 Mechanims of imr Normal leaflets Type I - IIIb Incomplete mitral leaflet closure Decreased closing forces due to global (and( regional) ) LV dysfunction Annular dilatation Increased tethering forces: - apical displacement of PM - increased tethering distance and tenting area - systolic restriction of the posterior ± anterior leaflets - bending of mid anterior leaflet (seagull sign)
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