2016 update to The American Association for Thoracic Surgery (AATS) consensus guidelines: Ischemic mitral valve regurgitation

Interpapillary muscle distance independently predicts recurrent mitral regurgitation

OBJECTIVE

Ischaemic secondary mitral regurgitation (ISMR) after surgery is due to the displacement of papillary muscles resulting from progressive enlargement of the left ventricle end-diastolic diameter (LVEDD). Our aim was to prove that if the interpapillary muscle distance (IPMD) is surgically stabilized, an increase in LVEDD will not lead to a recurrence of ischaemic mitral regurgitation (MR).

METHODS

Ninety-six patients with ISMR, who underwent surgical revascularisation and annuloplasty, were randomly assigned in a 1:1 ratio to undergo papillary muscle approximation (PMA). At the 5-year follow-up, we assessed the correlation between PMA and echocardiographic improvements, the effect size of PMA on echocardiographic improvements, and a prediction model for recurrent MR using inferential tree analysis.

RESULTS

There was a significant correlation between PMA and enhancements in both the α and β angles (Spearman's rho > 0.7, p < 0.01). The α angle represents the angle between the annular plane and either the A2 annular-coaptation line or the P2 annular-coaptation line. The β angle indicates the angle between the annular plane and either the A2 annular-leaflet tip line or the P2 annular-leaflet tip line. PMA led to substantial improvements in LVEDD, tenting area, α and β angles, with a large effect size (Hedge's g ≥ 8, 95% CI ORs ≠ 1). The most reliable predictor of recurrent MR grade was the interpapillary distance, as only patients with an interpapillary distance greater than 40 mm developed ≥ 3 + grade MR. For patients with an IPMD of 40 mm or less, the best predictor of recurrent MR grade was LVEDD. Among the patients, only those with LVEDD greater than 62 mm showed moderate (2+) MR, while only those with LVEDD less than or equal to 62 mm had absent to mild (1+) MR.

CONCLUSION

Prediction of recurrent ischaemic MR is not independent of progressive LVEDD increase. PMA-based surgical procedure stabilises IPMD.

Should moderate ischemic mitral regurgitation be corrected during coronary artery bypass grafting? a systematic review and meta-analysis

OBJECTIVE

Ischemic mitral regurgitation (IMR) is associated with increased risks of mortality and heart failure. However, the optimal management of moderate IMR remains controversial. We conducted a meta-analysis to appraise whether moderate IMR should be corrected during coronary artery bypass grafting (CABG).

METHODS

We searched PubMed, Embase, and Cochrane databases from its inception up to 15 October 2022 for studies that assessed CABG alone versus CABG with mitral valve (MV) surgery in patients with moderate IMR. The primary outcome was perioperative mortality.

RESULTS

Four randomized controlled trials and three observational studies with propensity-matched data including 1209 patients assessing CABG alone (n = 598) versus CABG with MV surgery (n = 611) were included. Compared to CABG alone, the addition of MV surgery did not significantly increase perioperative mortality (RR, 1.01; 95% CI, 0.52-1.96; p = 0.98) and stroke (RR, 2.14; 95% CI, 0.97-4.72; p = 0.06), whereas a longer cardiopulmonary bypass duration (MD, 54.91; 95% CI, 42.13-67.68; p < 0.01) and an increased incidence of renal failure were observed in the combined-procedure group. At follow-up, the addition of MV surgery was significantly associated with reduced rates of residual MR (RR, 0.26; 95% CI, 0.13-0.51; p < 0.01) and NYHA class III-IV (RR, 0.54; 95% CI, 0.37-0.78; p < 0.01). However, there was no difference in either mid-term mortality (RR, 1.05; 95% CI, 0.65-1.70; p = 0.82) or late mortality (RR, 91; 95% CI, 0.49-1.71; p = 0.78) between the CABG alone group and the combined-procedure group.

CONCLUSIONS

In patients with moderate IMR, the addition of MV surgery to CABG did not increase perioperative mortality. Despite the reduced rates of moderate MR and NYHA class III-IV at follow-up, the addition of MV surgery did not translate in a reduction in mid-term or late mortality.

Long-term outcome of isolated mitral valve repair versus replacement for degenerative mitral regurgitation in propensity-matched patients

Objective

This study was performed to investigate the long-term outcomes in patients with degenerative mitral regurgitation (MR) undergoing mitral valve repair (MVr) versus mitral valve replacement (MVR) without concomitant surgeries.

Methods

The study cohort comprised 1493 patients with degenerative MR who were treated with isolated mitral valve surgery between January 2000 and December 2017 in a large multicenter (5 hospitals) registry of the Province of British Columbia, Canada, including 991 with repair and 502 with replacement. A propensity-matched comparison and risk-adjusted model were used to analyze the outcomes.

Results

After propensity matching (415 matched pairs), the 30-day mortalities were 2.4% and 3.6% in the MVr and MVR groups respectively (odds ratio [OR], 1.500; 95% confidence interval [CI], 0.674-3.339; P = .32). The MVR group had significantly greater rates of prolonged inotrope usage >24 hours (P = .024), prolonged ventilation (P = .039), and blood transfusion (P = .023). The respective 1-, 5-, 10-, and 15-year survival rates were 95.7%, 88.8%, 71.4%, and 53.3% in the MVr group, and 93.0%, 81.6%, 61.3%, and 46.0% in the MVR group (hazard ratio [HR], 1.355; 95% CI, 1.105-1.661; P = .004). A multivariable analysis revealed that MVR was an independent risk factor for 30-day mortality (OR, 2.270; 95% CI, 1.089-4.732; P = .029) and long-term mortality (HR, 1.417; 95% CI, 1.161-1.729; P < .001). The HR of MVR over MVr remained consistently greater than 1.0 across all ages.

Conclusions

MVr is associated with lower postoperative morbidity and better long-term survival compared with MVR in patients undergoing isolated mitral valve surgery for degenerative MR. The benefit of MVr appears age-independent.

Concomitant Mitral Valve Surgery Versus No Intervention in Patients with Moderate Ischemic Mitral Regurgitation Undergoing Coronary Artery Bypass Grafting: A Propensity Score Analysis

Objectives

Ischemic mitral valve regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) is associated with worse long-term outcomes. This study aimed to assess the impact of mitral valve repair with CABG in patients with moderate IMR.

Materials

This observational study enrolled 3,215 consecutive patients from the Juntendo CABG registry with moderate IMR and multivessel coronary artery disease who underwent CABG between 2002 and 2017.

Methods

The CABG alone and CABG with mitral valve surgery (MVs) groups were compared. The propensity score was calculated for each patient. Long-term all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were compared.

Results

Our database had 101 patients who underwent CABG with moderate IMR. Propensity score matching selected 40 pairs for final analysis. MVs was associated with increased risks of postoperative atrial fibrillation, blood transfusion, and longer hospitalization. Long-term outcomes, including all-cause mortality, cardiac mortality, and the incidence of MACCEs were similar.

Conclusion

Surgical treatment of moderate IMR combined with CABG was related to increased risk of several non-fatal short-term complications when compared to CABG alone, with similar long-term outcomes. Further studies are needed to determine the effects of MVs in patients with moderate IMR and severe coronary artery disease.

Five-year follow-up of mitral valve repair versus replacement: a propensity score analysis

BACKGROUND

Mitral valve repair (MVRe) is considered to have a superior outcome compared to replacement (MVRp) in patients with mitral valve regurgitation (MVR). It was the aim of the study to analyse the clinical results and identify risk factors for short and long-term mortality.

METHODS

In a retrospective single-center analysis, patients undergoing an isolated mitral valve procedure from June 2010 to December 2016 were identified. These were subsequently homogenized using 10 baseline characteristics for propensity-score matching. Comparative analyses were performed for early and long-term results, using adequate statistical tools, and identifying risk factors for the investigated endpoints, primary end-point: all-cause mortality within 5 years and secondary end-points: recurrent MVR, reoperation, endocarditis and/or mortality with 30 days, 1, 3 and 5 years.

RESULTS

241 patients were identified in the entire patient cohort. After matching, patients were divided into 2 groups of 64 each respectively. The median age was similar in the two groups. There was a significant interaction between early mortality risk of MV in patients with coronary artery disease (CAD) (OR 11.94, 95% CI 1.49-285.92, p = 0.04) and late mortality in patients with higher EuroSCORE II (HR 1.14, 95% CI 1.06-1.23, p < 0.001). The primary end-point showed 5-year survival rate was significantly higher in MVRe versus MVRp (90.06% vs. 79.54% respectively, p = 0.04). The secondary end-point demonstrated recurrent MVR not to be statistically significant between the 2 groups (p = 0.09) as well as reoperation (p = 0.28). Endocarditis was observed in one patient after MVRp.

CONCLUSIONS

We concluded MVRe to be associated with lower operative and 5-year mortality and good postoperative outcomes compared to patients undergoing MVRp. Concomitant CAD was identified as one of the risk factors for increasing the in-hospital mortality rate. There was no significant difference in rehospitalisation over the follow-up period. MVRe should be the treatment of choice for severe MVR and should remain a central aspect in valve centers' treatment algorithms and quality measures.

Contemporary Management of Ischemic Mitral Regurgitation at Coronary Artery Bypass Grafting

BACKGROUND

Recent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase.

METHODS

Patients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score-matched analyses were used to compare patients with and without mitral intervention.

RESULTS

A total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; P_trend = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; P_trend = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5).

CONCLUSIONS

Consistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity.

Mitral regurgitation management: a systematic review of clinical practice guidelines and recommendations

Multiple guidelines exist for the diagnosis and management of mitral regurgitation (MR), the second most common valvular heart disease in high-income countries, with recommendations that do not always match. We systematically reviewed guidelines on diagnosis and management of MR, highlighting similarities and differences to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (1 June 2010 to 1 September 2021), the Guidelines International Network, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two reviewers independently screened the abstracts and identified articles of interest. Guidelines that were rigorously developed (as assessed with the Appraisal of Guidelines for Research and Evaluation II instrument) were retained for analysis. Five guidelines were retained. There was consensus on a multidisciplinary approach from the heart team and for the definition and grading of severe primary MR. There was general agreement on the thresholds for intervention in symptomatic and asymptomatic primary MR; however, discrepancies were present. There was agreement on optimization of medical therapy in severe secondary MR and intervention in patients symptomatic despite optimal medical therapy, but no consensus on the choice of intervention (surgical repair/replacement vs. transcatheter approach). Cut-offs for high-risk intervention in MR, risk stratification of progressive MR, and guidance on mixed valvular disease were sparse.

Variable definitions and treatment approaches for atrial functional mitral regurgitation: A scoping review of the literature

OBJECTIVES

Atrial functional mitral regurgitation (AFMR) is a subtype of functional mitral regurgitation due to longstanding atrial fibrillation (AF) or heart failure with preserved ejection fraction. The variation in AFMR' definition and the common mode of treatment described in the literature remain unknown.

METHODS

We performed a scoping review of studies that surgically treated AFMR to characterize the existing variability in the definition of AFMR, the type of operations performed for AFMR valvulopathy, and the treatment for the chronic AF. We searched Medline, EMBASE, Cochrane Library, Scopus, and Web of Science since their inceptions for studies of patients affected by AFMR and surgically treated for their valvulopathy.

RESULTS

Twelve studies (n = 494 patients) met eligibility criteria. All studies excluded patients with signs of left ventricular (LV) dysfunction, but the way additional parameters were used to define AFMR at a more granular level varied across studies: nine studies (75%) used the presence of AF to define their AFMR cohorts, with five (41.2%) requiring a history of AF of >1 year; additionally, the threshold values for the LV ejection fraction differed (45%-55%). Isolated mitral annuloplasty was performed in 96.2% of patients. Broad variability was detected in the proportion of patients undergoing the Cox-Maze procedure (range, 17.8%-79.5%), pulmonary vein isolation (0.0%-66.7%), and left atrial appendage ligation (0.0%-100.0%).

CONCLUSIONS

AFMR remains variably defined in surgical studies, making comparisons across studies difficult. Mitral annuloplasty was most commonly performed. The proportion of AFMR patients undergoing concomitant procedures for AF varied substantially.

Contemporary contribution of cardiac surgery for the treatment of cardiomyopathies and pericardial diseases

Cardiomyopathy refers to a spectrum of heterogeneous myocardial disorders characterized by morphological and structural alterations leading eventually to heart failure, by affecting cardiac filling and/or the cardiac systolic function. Heart transplantation is currently the gold standard surgical treatment for patients with heart failure, with a median survival in adults of 12 years according to international registries. However, the limited available donor pool does not allow its extensive employment. For this reason, mechanical circulatory supports are increasingly used, and in the short term are becoming as possible alternatives to heart transplantation, owing to improved technologies and increased biocompatibility. However, long-term outcomes of mechanical assist devices are still burdened with a high rate of adverse events. Conventional surgical treatments could be still considered as alternatives to heart replacement treatment when tailored both on patient clinical conditions and etiology of cardiac diseases. In particular, among patients affected by ischemic cardiomyopathy, coronary artery bypass grafting has proven to improve survival when associated to optimal medical treatment, and surgical ventricular restoration might be considered as a valid treatment in particular cases. Correction of functional mitral valve regurgitation by mitral annuloplasty, which aims to restore left ventricular geometry, has not demonstrated unambiguous results, and outcomes of this procedure are still controversial. Pericardial pathology becomes of surgical interest when it is responsible for a reduced filling capacity of the heart chambers, which can develop acutely (cardiac tamponade) or chronically (as in the case of constrictive pericarditis). This review focuses on the different surgical approaches that could be adopted to treat patients with heart failure and pericardial diseases.

Percutaneous Mitral Valve Annuloplasty in Patients With Secondary Mitral Regurgitation and Severe Left Ventricular Enlargement

OBJECTIVES

This study sought to determine the effect of percutaneous mitral valve annuloplasty with the Carillon device versus guideline-directed medical therapy (GDMT) alone in patients with secondary mitral regurgitation (MR) and severe left ventricular (LV) enlargement.

BACKGROUND

The clinical impact of the Carillon device in patients with severe LV dilation is not well established.

METHODS

This is a pooled analysis involving 3 prospective trials (TITAN [Transcatheter Implantation of Carillon Mitral Annuloplasty Device], TITAN II, and REDUCE FMR [CARILLON Mitral Contour System for Reducing Functional Mitral Regurgitation] trials) in which patients with functional MR and severe LV enlargement (LV end-diastolic diameter >65 mm) were treated with GDMT and the Carillon device versus GDMT alone. Key outcomes of this analysis were changes over 1 year of follow-up in mitral valve and LV echocardiographic parameters, functional outcome, quality of life, mortality, and heart failure hospitalization (HFH).

RESULTS

A total of 95 patients (67 in the Carillon group, 28 in the GDMT group) with severe LV enlargement were included. In the Carillon group, all mitral valve and LV morphology parameters were significantly improved at 1 year. Regurgitant volume decreased by 12 ml (p < 0.001), MR grade decreased by 0.6 U (p < 0.001), LV end-diastolic volume decreased by 25 cm3 (p = 0.005), and LV end-systolic volume decreased by 21 cm3 (p = 0.01). Significant functional improvement differences were also noted between the Carillon group and the GDMT group including an improvement of Kansas City Cardiomyopathy Questionnaire score (15 ± 4 vs. 6 ± 6; p = 0.03). The incidence of HFH was 29.9% versus 50.0% and the cumulative rate of HFH was 0.43 versus 0.75 (p < 0.001).

CONCLUSIONS

In patients with functional MR and severe LV enlargement, the Carillon device improved mitral valve function, LV morphology, and functional outcome compared with patients receiving GDMT only. Preoperative LV dimension should not be a limiting factor when evaluating patient eligibility or anticipated response to therapy with the Carillon device.

Ischemic functional mitral regurgitation: from pathophysiological concepts to current treatment options. A systemic review for optimal strategy

OBJECTIVE

The current treatment of ischemic functional mitral regurgitation (FMR) remains debated due to differences in inclusion criteria of randomized studies and baseline characteristics. Also, the role of left ventricular pathophysiology and the role of subvalvular apparatus have not been thoroughly investigated in recent literature.

METHODS

A literature search was performed from PubMed inception to June 2020.

RESULTS

Novel concepts of pathophysiology, such as the proportionate/disproportionate conceptual framework, the role of papillary muscles and left ventricular dysfunction, the impact of myocardial ischemia and revascularization, left ventricular remodeling, and the effect of restrictive annuloplasty or subvalvular procedures have been reviewed.

CONCLUSIONS

The clinical benefits associated with the use of MitraClip is more evident in patients with disproportionate FMR with greater and sustained left ventricular reverse remodeling. Importantly, in the absence of myocardial revascularization, expansion of myocardial scar tissue and non-perfused areas of ischemic myocardium occur with time, and this impact on outcomes with a longer follow-up period cannot be quantified. In advanced phases of FMR, neither mitral ring annuloplasty nor percutaneous therapies could significantly modify the established pathoanatomic alterations.

Long Term Survival After Surgery for Ischaemic Mitral Regurgitation: A Single Centre Australian Experience

BACKGROUND

Ischaemic mitral regurgitation (IMR) is associated with an increase in both mortality and congestive heart failure in patients undergoing coronary artery bypass grafting (CABG). Intervention for moderate to severe IMR involves either valve repair or replacement. The ideal option is yet to be fully defined with relatively poor long-term survival being noted in the literature.

METHOD

A retrospective observational study was conducted to review the outcomes of patients undergoing CABG in combination with either mitral valve repair (MVr) or mitral valve replacement (MVR) for concurrent coronary artery disease with moderate to severe IMR at The Prince Charles Hospital in Brisbane between the years 2002 to 2015.

RESULTS

One hundred and five (105) patients were included, 81 patients (77%) undergoing CABG and MVr and 24 patients (23%) undergoing CABG and MVR. There was no difference in 30-day mortality between the two groups (1% in MVr and 0% in MVR, p=0.589), however patients in the MVr group were significantly more likely, in univariate and multivariate analysis, to develop at least moderate MR (40% v. 8%, p=0.006). The 5-year survival was 87% and 55% at 10 years.

CONCLUSIONS

In patients undergoing CABG and mitral valve intervention for IMR, long-term mortality remains high. There was no difference in short- or long-term mortality between repair and replacement although recurrence of at least moderate mitral regurgitation was significantly higher with mitral valve repair.

Minimally invasive mitral valve repair for functional mitral regurgitation

Systolic heart failure is frequently accompanied by a relevant functional mitral valve regurgitation (FMR) which develops as a direct sequela of the ongoing left ventricular remodelling. The severity of mitral regurgitation is further aggravated by progressive left ventricular enlargement causing leaflet tethering and reduced systolic leaflet movement. The prognosis of such patients is obviously limited by an underlying left ventricular disease, and the correction of secondary FMR has been previously suggested as predominantly ‘cosmetic’ surgery in the setting of ongoing cardiomyopathy. Inferior results of an isolated annuloplasty in type IIIb FMR supported the philosophy of malignant course of progressive cardiomyopathy and resulted in increasingly restricted indications for mitral valve surgery for FMR in the guidelines. The lack of a standardized pathophysiological approach to correct type IIIb FMR led to the development of valve replacement strategy and edge-to-edge catheter-based mitral valve procedures, which became the most frequent procedures in the FMR setting in Europe. Modern mitral valve surgery combines the advantages of 3-dimensional endoscopic minimally invasive surgical approach with standardized subannular repair to address the pathophysiological background of type IIIb FMR. The perioperative results have been significantly improved, and there is a growing evidence of improved long-term stability of subannular repair procedures as compared to isolated annuloplasty. This review article aims to present the current state-of-the-art of the modern mitral valve surgery in FMR and provides suggestions for future trials analysing the potential advantages in these patients.

Atrial functional mitral regurgitation: mechanisms and surgical implications

The term atrial functional mitral regurgitation refers to a newly recognized disease entity in which mitral regurgitation occurs secondary to left atrial disease, without left ventricular dilatation and intrinsic mitral valve disease, typically in the setting of long-standing atrial fibrillation. Recent evidence suggests that atrial functional mitral regurgitation is associated with increased risk of death and heart failure re-hospitalization. The etiology, pathophysiology, and mechanism of atrial functional mitral regurgitation is not completely understood but they should not be regarded as the same as for the conventional type of functional mitral regurgitation secondary to left ventricular dilatation and dysfunction. Mitral annular dilatation, atriogenic leaflet distortion, insufficient leaflet remodeling, and subtle left ventricular dysfunction may play a role in the pathogenesis of atrial functional mitral regurgitation. The therapeutic and surgical considerations of atrial functional mitral regurgitation are different from those of ventricular functional mitral regurgitation. In this review, we assess current evidence regarding this new disease entity and propose a new surgical approach based on up-to-date understanding and experience of this condition.

The Choice of Treatment in Ischemic Mitral Regurgitation With Reduced Left Ventricular Function

BACKGROUND

Ischemic mitral regurgitation is a condition characterized by mitral insufficiency secondary to an ischemic left ventricle. Primarily, the pathology is the result of perturbation of normal regional left ventricular geometry combined with adverse remodeling. We present a comprehensive review of contemporary surgical, medical, and percutaneous treatment options for ischemic mitral regurgitation, rigorously examined by current guidelines and literature.

METHODS

We conducted a literature search of the PubMed database, Embase, and the Cochrane Library (through November 2018) for studies reporting perioperative or late mortality and echocardiographic outcomes after surgical and nonsurgical intervention for ischemic mitral regurgitation.

RESULTS

Treatment of this condition is challenging and often requires a multimodality approach. These patients usually have multiple comorbidities that may preclude surgery as a viable option. A multidisciplinary team discussion is crucial in optimizing outcomes. There are several options for treatment and management of ischemic mitral regurgitation with differing benefits and risks. Guideline-directed medical therapy for heart failure is the treatment choice for moderate and severe ischemic mitral regurgitation, with consideration of coronary revascularization, mitral valve surgery, cardiac resynchronization therapy, or a combination of these, in appropriate candidates. The use of transcatheter mitral valve therapy is considered appropriate in high-risk patients with severe ischemic mitral regurgitation, heart failure, and reduced left ventricular ejection fraction, especially in those with hemodynamic instability.

CONCLUSIONS

The role of mitral valve surgery and transcatheter mitral valve therapy continues to evolve.

Transcatheter mitral valve repair: review of the clinical evidence

Over the past decade, different transcatheter repair techniques have been developed to treat mitral regurgitation (MR) with less invasive approaches in order to address the unmet clinical need of untreated patients with MR. The aim of this report is to provide an overview of the currently available transcatheter mitral repair options, focusing on the evidence reported so far.

Ischemic Mitral Regurgitation: Repair, Replacement or Nothing

The treatment strategy for ischemic mitral regurgitation (MR) continues to evolve with the completion of multicenter trials and the advancement of surgical and percutaneous interventional techniques. This review defines ischemic MR, outlines key clinical trials that assess surgical and interventional approaches, and reports the main elements of recent national guidelines for decision making in treatment of ischemic MR. New findings in percutaneous mitral valve repair and replacement for ischemic MR will also be described. Effective perioperative care of patients with ischemic MR requires clinicians to be well versed in the most up-to-date recommendations and emerging technological developments.

Contemporary Management of Ischemic Mitral Regurgitation: A Review

Ischemic mitral regurgitation occurs relatively frequently in patients with coronary artery disease and is associated with an increased long-term risk. The pathophysiology of ischemic mitral regurgitation is vexing and poses both diagnostic and therapeutic challenges, leading to the need for a comprehensive, multidisciplinary approach. The management is largely focused on medical therapy, and for those eligible, coronary revascularization or cardiac resynchronization therapy may be considered. In select patients, mitral valve surgery or catheter-based therapy may be undertaken with careful consideration of the underlying pathophysiology, surgical risk, and expected long-term outcomes. The appropriate evaluation of patients with ischemic mitral regurgitation involves a careful multidisciplinary approach that carefully considers symptomatology, the etiology and severity of the mitral regurgitation, and the assessment of comorbidities and operative risk to individualize the care of these patients.

Functional mitral regurgitation: an overview for surgical management framework

Functional mitral regurgitation (FMR) is one the most common complications of myocardial infarction (MI) in adults carrying a significant clinical and economic burden. Despite specific randomized controlled studies to address its treatment have been performed, there are still a number of questions remained unanswered. Outcomes of surgical repair of FMR are still hampered by a significant rate of recurrence of regurgitation and need for reoperation. Mechanisms underlying failure of repairs still need to be completely clarified and questions regarding the indications and optimal timing for intervention as well as the best suitable operative technique to be applied are still debated. This work will review the current knowledge on FMR including its pathogenic mechanisms, the available treatment strategies, the evidences from trials and observational studies and the potential future directions to address the issues related to its treatment.