Ischaemic mitral regurgitation: pathophysiology, outcomes and the conundrum of treatment

• Published in: European heart journal Vol. 31; no. 24; pp. 2996 - 3005
• Main Authors: Piérard, Luc A., Carabello, Blase A.
• Format: Journal Article Web Resource
• Language: English
• Published: Oxford Oxford University Press 01.12.2010
• Subjects: Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors - therapeutic use; Biological and medical sciences; Cardiac Resynchronization Therapy; Cardiology. Vascular system; Cardiovascular system; Chronic Disease; Coronary Artery Disease - complications; Echocardiography; Endocardial and cardiac valvular diseases; General & internal medicine; Heart; Human health sciences; Humans; Investigative techniques, diagnostic techniques (general aspects); Medical sciences; Mitral valve; Mitral Valve Insufficiency - diagnosis; Mitral Valve Insufficiency - etiology; Mitral Valve Insufficiency - therapy; Myocardial Ischemia - complications; Médecine générale & interne; Prognosis; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects); Sciences de la santé humaine; Surgery; Ultrasonic investigative techniques; Ventricular Dysfunction, Left - etiology; Ventricular Remodeling - physiology; Sonography; Cardiac resynchronization; Mitral valve; Echocardiography; Prognosis; Pathophysiology; Instrumentation therapy; Cardiovascular disease; Cardiac resynchronization therapy; Instrumental stimulation; Ischemia; Cardiac valvular disease; Surgery; Mitral regurgitation; Circulatory system; Cardiology
• ISSN: 0195-668X; 1522-9645; 1522-9645
• DOI: 10.1093/eurheartj/ehq411

Ischaemic mitral regurgitation is a frequent complication of left ventricular global or regional pathological remodelling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces (papillary muscles displacement leading to a more apical position of the leaflets and their coaptation point) and reduced closing forces (reduced contractility, dyssynchrony of the papillary muscles, intra-left ventricular dyssynchrony). Although mitral regurgitation has an unloading effect and reduces impedance, the volume overload begets further left ventricular dilatation, increases ventricular wall stress leading to worsened performance. Ischaemic mitral regurgitation is characteristically dynamic: its severity may vary with haemodynamic conditions. Both the severity of ischaemic mitral regurgitation and its dynamic component worsen prognosis. There are numerous possible treatment modalities, but the management of the individual patient remains difficult. Medical therapy is mandatory; revascularization procedures are frequently not sufficient to reduce mitral regurgitation; the role of combined surgical therapy by mitral valve repair is not yet defined in the absence of large randomized trial. Some patients are good candidates for cardiac resynchronization therapy that may reduce the amount of regurgitation. New therapeutic targets are under investigation.