ischemic mitral regurgitation - cardiologie francophone · ischemic mitral regurgitation is mitral...

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.


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


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


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



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



ERO > 20 mmERO > 20 mm22

andand/or/orRV > 30 mLRV > 30 mL

adjustedadjusted RR: 2.01 RR: 2.01 -- 2.382.38



Ischemic Mitral RegurgitationIschemic Mitral RegurgitationPrognosticPrognostic value value ofof MR in MR in ischemicischemic heartheart diseasedisease



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



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%


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


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%


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


Type IIIbType IIIbLeafletLeaflet restrictionrestriction

Ischemic mitralIschemic mitral regurgitation: Type III dysfunctionregurgitation: Type III dysfunction


•• 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



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


--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


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



IschemicIschemic mitralmitral regurgitation: Increased tentingregurgitation: Increased tenting


YiuYiu et al., et al., Circulation Circulation 2000;102:14002000;102:1400

Ischemic mitral regurgitation: Increased tentingIschemic mitral regurgitation: Increased tenting

Tenting areaTenting area



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




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 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


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


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



Ischemic Mitral RegurgitationIschemic Mitral RegurgitationImpact of exerciseImpact of exercise--induced mitral regurgitation on exercise toleranceinduced mitral regurgitation on exercise tolerance


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


% 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)



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




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


Lancellotti et al., Lancellotti et al., CirculationCirculation 2003;108:1713.2003;108:1713.

66


•• 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


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%


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


GuyGuy et al., et al., J Am Coll CardiolJ Am Coll Cardiol 20042004;;4343::377377

Late Late postpost--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


PrePre--opop

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

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


baselinebaseline inferiorinferior ischemiaischemia inferiorinferior + PM+ PMchordae cuttingchordae cutting

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




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


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


ChronicChronic MIMI Acute plicationAcute plication Chronic plicationChronic 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


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




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))

ischemic mitral regurgitation - cardiologie francophone · ischemic mitral regurgitation is mitral...

Documents