ISCHEMIC MITRAL REGURGITATION – TO REPAIR OR REPLACE? LOOKING BEYOND THE VALVE
DOI:
https://doi.org/10.48729/pjctvs.253Abstract
Introduction: Ischemic mitral regurgitation (IMR) is a frequent and serious complication of coronary artery disease, associated with considerable patient increased mortality and morbidity. While the benefits of optimal medical therapy and surgical revascularization, when indicated, are uncontested in moderate to severe cases, the ideal surgical approach to the valve, if any, is yet to be established.
Mitral valve repair has established benefits over replacement in primary mitral regurgitation, but its superiority in the treatment of functional regurgitation has not been replicated.
Differing outcomes likely stem from the distinct IMR pathophysiology. Unlike its degenerative counterparts, IMR does not derive from direct damage to the valve leaflets, but rather from dysfunction of its sub-valvular apparatus and the left ventricular wall, in the context of acute or chronic ischaemia. Echocardiographic data points to remodelling of the left ventricle, with subsequent papillary muscle displacement, increased leaflet tethering and inefficient coaptation, as the main responsible mechanism for ischemic mitral regurgitation. Neither mitral valve repair nor replacement directly address these issues, with the appearance of the first randomized trials supporting replacement as the more durable option. However, new subvalvular procedures are improving the stability of repair techniques and the debate is long from settled.
The purpose of this review is to analyse the currently available data, couple it with our understanding of IMR’s pathophysiology and compare the different outcomes for mitral valve repair and replacement.
Downloads
References
Hickey M, Smith L, Muhlbaier L, et al. Current prognosis of ischemic mitral regurgitation. Implications for future management. Circulation. 1988;78(3):51-59.
Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community:
The emerging role of mitral regurgitation. Circulation. 2005;111(3):295-301. doi:10.1161/01.CIR.0000151097.30779.04
Lamas GA, Mitchell GF, Flaker GC, et al. Clinical significance of mitral regurgitation after acute myocardial infarction. Circulation. 1997;96(3):827-833.
Lehmann KG, Francis CK, Dodge HT. Mitral Regurgitation in Early Myocardial Infarction: Incidence, Clinical Detection,
and Prognostic Implications. Annals of Internal Medicine. 1992;117(1):10-17.
Tcheng J, Jackman JJ, Nelson C, et al. Outcome of patients sustaining acute ischemic mitral regurgitation during myocardial infarction. Annals of Internal Medicine. 1992;117(1):18-24.
Mihaljevic T, Lam BK, Rajeswaran J, et al. Impact of Mitral Valve Annuloplasty Combined With Revascularization in Patients With Functional Ischemic Mitral Regurgitation. Journal of the American College of Cardiology. 2007;49(22):2191-2201. doi:10.1016/j.jacc.2007.02.043
Wu AH, Aaronson KD, Bolling SF, Pagani FD, Welch K, Koelling TM. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. Journal of the American College of Cardiology. 2005;45(3):381-387. doi:10.1016/j.jacc.2004.09.073
Perloff JK, Roberts WC. The Mitral Apparatus Functional Anatomy of Mitral Regurgitation.
Rusted BIANE, Scheifley CH, Edwards JE. Studies of the Mitral Valve . I . Anatomic Features of the Normal Mitral Valve and Associated Structures. Circulation. 1952;6(December): 825-831. doi:10.1161/01.CIR.6.6.825
Kouchoukos N, Blackstone EH, Hanley FL, Kirklin JK. Kirklin/Barratt-Boyes’ Cardiac Surgery.; 2013.
Barbour DJ, Roberts WC. Rupture of a left ventricular papillary muscle during acute myocardial infarction: analysis of 22 necropsy patients. Journal of the American College of Cardiology. 1986;8(3):558-565. doi:10.1016/S0735-1097(86)80182-6
Nishimura R, Schaff H, Shub C, Gersh B, Edwards W, Tajik A. Papillary muscle rupture complicating acute myocardial infarction: Analysis of 17 patients. The American Journal of Cardiology. 1983;51(3):373-377.
Wei J, Hutchins G, Bulkley BH. Papillary muscle rupture in fatal acute myocardial infarction: a potentially treatable form of cardiogenic shock. Annals of Internal Medicine. 1979;90(2):149-152.
He S, Fontaine AA, Schwammenthal E, Yoganathan AA, Levine RA. Mechanism for Functional Mitral Regurgitation - Leaflet Restriction Versus Coapting Force In Vitro Studies. Circulation. 1997;96:1826-1834.
Griffin B. Manual of Cardiovascular Medicine 4th Edition.
Kaul S, Spotnitz W, Glasheen W, Touchstone DA. Mechanism of ischemic mitral regurgitation. An experimental evaluation. Circulation. 1991;84(5):2167-2180.
Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik a J. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation. 2000;102(12):1400-1406. doi:10.1161/01.CIR.102.12.1400
Burch GE, DePasquale NP, Phillips JH. The syndrome of papillary muscle dysfunction. American heart journal. 1968;75(3):399-415.
Godley RW, Wann LS, Rogers EW, Feigenbaum H, Weyman a E. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation. 1981;63(3):565-571. doi:10.1161/01.CIR.63.3.565
Boltwood CM, Tei C, Wong M, Shah PM. Quantitative echocardiography of the mitral complex in dilated cardiomyopathy: the mechanism of functional mitral regurgitation. Circulation. 1983;68(3):498-508. doi:10.1161/01. CIR.68.3.498
Sabbah H, Kono T, Stein P, Mancini G, Goldstein S. Left ventricular shape changes during the course of evolving heart failure. American Journal of Physiology. 1992;263(1):266-270.
Kono T, Sabbah HN, Stein P, Brymer J, Khaja F. Left ventricular shape as a determinant of functional mitral regurgitation in patients with severe heart failure secondary to either coronary artery disease or idiopathic dilated cardiomyopathy. Journal of the American College of Cardiology. 1991;68(4):355-359.
Kono T, Sabbah HN, Rosman H, et al. Mechanism of functional mitral regurgitation during acute myocardial ischemia. Journal of the American College of Cardiology. 1992;19(5):1101-1105.
Kumanohoso T, Otsuji Y, Yoshifuku S, et al. Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: Quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. Journal of Thoracic and Cardiovascular Surgery. 2003;125(1):135-143. doi:10.1067/mtc.2003.78
Carpentier A, Adams DH, Filsoufi F. Carpentier’s Reconstructive Valve Surgery.; 2010.
van Dantzig J, Delemarre B, Koster R, Bot H, Visser C. Pathogenesis of mitral regurgitation in acute myocardial infarction: Importance of changes in left ventricular shape and regional function. American Heart Journal. 1996;131(5):865-871.
Kang DH, Park SJ, Shin SH, et al. Angiotensin Receptor Neprilysin Inhibitor for Functional Mitral Regurgitation: PRIME Study. Circulation. 2019;139(11):1354-1365. doi:10.1161/CIRCULATIONAHA.118.037077
Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal. 2022;43(7):561-632. doi:10.1093/eurheartj/ehab395
McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. 2021;42(36):3599-3726. doi:10.1093/eurheartj/ehab368
van Bommel RJ, Marsan NA, Delgado V, et al. Cardiac resynchronization therapy as a therapeutic option in patients with moderate-severe functional mitral regurgitation and high operative risk. Circulation. 2011;124(8):912-919. doi:10.1161/CIRCULATIONAHA.110.009803
Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/ Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online 2021:E72-E227. doi:10.1161/CIR.0000000000000923
Fattouch K, Guccione F, Sampognaro R, Panzarella G, Corrado E, Navarra E, Calvaruso D RG. Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. Journal of Thoracic and Cardiovascular Surgery. 2009;138(2):278-285.
Michler RE, Smith PK, Parides MK, et al. Two-Year Outcomes of Surgical Treatment of Moderate Ischemic Mitral Regurgitation. New England Journal of Medicine. Published online 2016:NEJMoa1602003. doi:10.1056/NEJMoa1602003
Roussin I, Rahman-Haley S, Pennell DJ, et al. Ischemic Mitral Evaluation (RIME) Trial Moderate Functional Ischemic Mitral Regurgitation : Final Results of the Randomized Coronary Artery Bypass Surgery With or Without Mitral Valve Annuloplasty in Valvular Heart Disease Coronary Artery Bypass Surgery With or Without Mitral Valve Annuloplasty in Moderate Functional Ischemic Mitral Regurgitation Final Results of the Randomized Ischemic Mitral Evaluation (RIME) Trial. Published online 2012. doi:10.1161/CIRCULATIONAHA
di Donato M, Castelvecchio S, Menicanti L. End-systolic volume following surgical ventricular reconstruction impacts survival in patients with ischaemic dilated cardiomyopathy. European Journal of Heart Failure. 2010;12(4):375-381. doi:10.1093/eurjhf/hfq020
Petrus AHJ, Tops LF, Timmer E, et al. Prognostic value of left ventricular reverse remodelling and recurrent mitral regurgitation after personalized surgical treatment of patients with non-ischaemic cardiomyopathy and functional mitral regurgitation. Interactive Cardiovascular and Thoracic Surgery. 2018;27(5):657-663. doi:10.1093/icvts/ivy161
Michler RE. Surgical management of moderate ischemic mitral regurgitation at the time of coronary artery bypass grafting remains controversial. Journal of Thoracic and Cardiovascular Surgery. 2018;156(4):1498-1500. doi:10.1016/j.jtcvs.2018.05.060
Penicka M, Linkova H, Lang O, et al. Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery. Circulation. 2009;120(15):1474-1481. doi:10.1161/CIRCULATIONAHA.108.842104
Braun J, Bax JJ, Versteegh MIM, et al. Preoperative left ventricular dimensions predict reverse remodeling following restrictive mitral annuloplasty in ischemic mitral regurgitation. European Journal of Cardio-thoracic Surgery. 2005;27(5):847-853. doi:10.1016/j.ejcts.2004.12.031
Bouma W, van der Horst ICC, Wijdh-den Hamer IJ, et al. Chronic ischaemic mitral regurgitation. Current treatment results and new mechanism-based surgical approaches. European Journal of Cardio-thoracic Surgery. 2010;37(1):170-185. doi:10.1016/j.ejcts.2009.07.008
Braun J, van de Veire NR, Klautz RJM, et al. Restrictive Mitral Annuloplasty Cures Ischemic Mitral Regurgitation and Heart Failure. Annals of Thoracic Surgery. 2008;85(2):430-437. doi:10.1016/j.athoracsur.2007.08.040
Grossi EA, Goldberg JD, LaPietra A, et al. Ischemic mitral valve reconstruction and replacement: Comparison of long-term survival and complications. Journal of Thoracic and Cardiovascular Surgery. 2001;122(6):1107-1124. doi:10.1067/mtc.2001.116945
Calafiore AM, Iaco AL, Tash A, Abukudair W, di Mauro M. Mitral valve surgery for functional mitral regurgitation in patients with chronic heart failure update of the results. Thoracic and Cardiovascular Surgeon. 2010;58(3):131-135.
Al-Radi OO, Austin PC, Tu J v., David TE, Yau TM. Mitral Repair Versus Replacement for Ischemic Mitral Regurgitation. Annals of Thoracic Surgery. 2005;79:1260-1267. doi:10.1016/j.athoracsur.2004.09.044
Silberman S, Oren A, Klutstein MW, et al. Does mitral valve intervention have an impact on late survival in ischemic cardiomyopathy? Israel Medical Association Journal. 2006;8(1):17-20.
Milano CA, Daneshmand MA, Rankin JS, et al. Survival Prognosis and Surgical Management of Ischemic Mitral Regurgitation. Annals of Thoracic Surgery. 2008;86(3):735-744. doi:10.1016/j.athoracsur.2008.05.017
Magne J, Girerd N, Sénéchal M, et al. Mitral repair versus replacement for ischemic mitral regurgitation comparison of short-term and long-term survival. Circulation. 2009;120(SUPPL. 1). doi:10.1161/CIRCULATIONAHA.108.843995
Vassileva CM, Boley T, Markwell S, Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation. European Journal of Cardio-thoracic Surgery. 2011;39(3):295-303. doi:10.1016/j.ejcts.2010.06.034
Dayan V, Soca G, Cura L, Mestres CA. Similar survival after mitral valve replacement or repair for ischemic mitral regurgitation: A meta-analysis. Annals of Thoracic Surgery. 2014;97(3):758-765. doi:10.1016/j.athoracsur.2013.10.044
Virk SA, Sriravindrarajah A, Dunn D, et al. A meta-analysis of mitral valve repair versus replacement for ischemic mitral regurgitation. Ann Cardiothorac Surg. 2015;4(5):400-410.
Yun-Dan D, Wen-Jing D, Xi-Jun X. Comparison of Outcomes following Mitral Valve Repair versus Replacement for Chronic Ischemic Mitral Regurgitation: A Meta-Analysis. Thoracic and Cardiovascular Surgeon. 2017;65(6):432-441. doi:10.1055/s-0036-1580603
Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. The New England journal of medicine. 2014;370(1):23-32. doi:10.1056/NEJMoa1312808
Rankin J, Feneley M, Hickey M, et al. A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation. The Journal of thoracic and cardiovascular surgery. 1988;95(2):165-177.
Mantovani V, Mariscalco G, Leva C, Blanzola C, Cattaneo P, Sala A. Long-Term Results of the Surgical Treatment of Chronic Ischemic Mitral Regurgitation: Comparison of Repair and Prosthetic Replacement. The Journal of Heart Valve Disease. 2004;13:421-429.
Bonacchi M, Prifti E, Maiani M, Frati G, Nathan NS, Leacche M. Mitral valve surgery simultaneous to coronary revascularization in patients with end-stage ischemic cardiomyopathy. Heart and Vessels. 2006;21(1):20-27. doi:10.1007/s00380-005-0853-5
Cohn LH, Rizzo RJ, Adams DH, et al. The effect of pathophysiology on the surgical treatment of ischemicmitral regurgitation: operative and late risks of repair versusreplacement. European Journal of Cardio-thoracic Surgery. 1995;9(10):568-574. doi:10.1016/S1010-7940(05)80008-9
Chan V, Ruel M, Mesana TG. Mitral Valve Replacement Is a Viable Alternative to Mitral Valve Repair for Ischemic Mitral Regurgitation: A Case-Matched Study. The Annals of Thoracic Surgery. 2011;92(4):1358-1366. doi:10.1016/j.athoracsur.2011.05.056
Lorusso R, Gelsomino S, Vizzardi E, et al. Mitral valve repair or replacement for ischemic mitral regurgitation? the Italian Study on the Treatment of Ischemic Mitral Regurgitation (ISTIMIR). Journal of Thoracic and Cardiovascular Surgery. 2013;145(1):128-139. doi:10.1016/j.jtcvs.2012.09.042
Goldstein D, Moskowitz AJ, Gelijns AC, et al. Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation. New England Journal of Medicine. Published online 2015.
Crabtree TD, Bailey MS, Moon MR, et al. Recurrent Mitral Regurgitation and Risk Factors for Early and Late Mortality After Mitral Valve Repair for Functional Ischemic Mitral Regurgitation. Annals of Thoracic Surgery. 2008;85(5):1537-1543. doi:10.1016/j.athoracsur.2008.01.079
Serri K, Bouchard D, Demers P, et al. Is a good perioperative echocardiographic result predictive of durability in ischemic mitral valve repair? Journal of Thoracic and Cardiovascular Surgery. 2006;131(3). doi:10.1016/j.jtcvs.2005.09.037
Magne J, Pibarot P, Dumesnil JG, S??n??chal M. Continued Global Left Ventricular Remodeling Is Not the Sole Mechanism Responsible for the Late Recurrence of Ischemic Mitral Regurgitation after Restrictive Annuloplasty. Journal of the American Society of Echocardiography. 2009;22(11):1256-1264. doi:10.1016/j.echo.2009.07.029
Ciarka A, Braun J, Delgado V, et al. Predictors of mitral regurgitation recurrence in patients with heart failure undergoing mitral valve annuloplasty. American Journal of Cardiology. 2010;106(3):395-401. doi:10.1016/j.amjcard.2010.03.042
Kron I, Hung J, Overbey J, et al. Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation. Journal of Thoracic and Cardiovascular Surgery. 2015;149(3):752-761.
Capoulade R, Zeng X, Overbey JR, et al. Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty. Circulation. 2016;134(17):1247-1256. doi:10.1161/CIRCULATIONAHA.115.021014
Petrus AHJ, Klautz RJM, de Bonis M, et al. The optimal treatment strategy for secondary mitral regurgitation: A subject of ongoing debate. European Journal of Cardio-thoracic Surgery. 2019;56(4):631-642. doi:10.1093/ejcts/ezz238
Qiu Z, Chen X, Xu M, et al. Is mitral valve repair superior to replacement for chronic ischemic mitral regurgitation with left ventricular dysfunction? Journal of Cardiothoracic Surgery. 2010;5(107).
Yoshida K, Okada K, Miyahara S, et al. Mitral valve replacement versus annuloplasty for treating severe functional
mitral regurgitation. General Thoracic and Cardiovascular Surgery. 2014;62(1):38-47. doi:10.1007/s11748-013-0297-2
Kron IL, Green GR, Cope JT. Surgical Relocation of the Posterior Papillary Muscle in Chronic Ischemic Mitral Regurgitation. Vol 74.; 2002.
Wakasa S, Shingu Y, Ooka T, Katoh H, Tachibana T. Surgical strategy for ischemic mitral regurgitation adopting subvalvular and ventricular procedures. Annals of Thoracic and Cardiovascular Surgery. 2015;21(4):370-377. doi:10.5761/atcs.oa.14-00204
Langer F, Kunihara T, Hell K, et al. RING+STRING Successful repair technique for ischemic mitral regurgitation with severe leaflet tethering. Circulation. 2009;120(SUPPL. 1). doi:10.1161/CIRCULATIONAHA.108.840173
Borger MA, Murphy PM, Alam A, et al. Initial results of the chordal-cutting operation for ischemic mitral regurgitation. Journal of Thoracic and Cardiovascular Surgery. 2007;133(6). doi:10.1016/j.jtcvs.2007.01.064
Harmel EK, Reichenspurner H, Girdauskas E. Subannular reconstruction in secondary mitral regurgitation: A meta- analysis. Heart. 2018;104(21):1783-1790. doi:10.1136/heartjnl-2017-312277
Mihos CG, Santana O. Is an adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation effective in preventing recurrent regurgitation? Interactive Cardiovascular and Thoracic Surgery. 2016;22(2):216-221. doi:10.1093/icvts/ivv328
