Ischemic mitral regurgitation: current understanding and surgical options

  • Alexander Angelo BresciaEmail author
  • Tessa Maria Fontana Watt
  • Steven Frederic Bolling
Review Article


Secondary, or functional, mitral regurgitation (MR) occurs with impaired coaptation of structurally normal valve leaflets due to abnormal structure and/or function of the left ventricle (LV). A leading cause of functional mitral regurgitation is ischemic cardiomyopathy, resulting in left ventricular dysfunction and subsequent congestive heart failure (CHF) and ischemic mitral regurgitation (IMR). The value of surgical or transcatheter correction of IMR remains controversial, since the underlying pathology of IMR is attributed to a dysfunctional left ventricle. However, even mild IMR has been shown to be harmful to CHF patients, as IMR is both a surrogate of advanced CHF and an independent contributor to CHF morbidity and mortality. While observational and randomized studies have examined surgical treatment of IMR with conflicting outcomes, additional well-designed randomized controlled trials should be performed to further clarify the optimal treatment for IMR. Additionally, close attention should be paid to the quality of interventions performed, as durable reduction in IMR provides the best hope of a positive clinical outcome. This review focuses on the pathophysiology of IMR, current evidence regarding surgical and transcatheter interventions, and future directions in management of IMR.


Functional mitral regurgitation Ischemic mitral regurgitation Mitral valve repair 


Funding information

Alexander Brescia is supported by the National Institutes of Health National Research Service Award postdoctoral fellowship (No. 5T32HL076123).

Compliance with ethical standards

Human and animal rights

Not applicable.

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

Not applicable.


  1. 1.
    Ward ST, Brescia AA, Romano MA, Bolling SF. Congestive heart failure: surgical techniques for functional mitral regurgitation. Operative cardiac surgery (Sixth edition). Boca Raton: CRC Press; 2018.Google Scholar
  2. 2.
    Brescia AA, Watt T, Bolling SF. Mitral Valve Repair for Congestive Heart Failure. Society of Thoracic Surgeons E-Book. In press.Google Scholar
  3. 3.
    Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation. 2005;112:745–58.CrossRefGoogle Scholar
  4. 4.
    Deja M, Grayburn P, Sun B, et al. Influence of mitral regurgitation repair on survival in the surgical treatment for ischemic heart failure trial. Circulation. 2012;125:2639–48.CrossRefGoogle Scholar
  5. 5.
    Nakai H, Kaku K, Takeuchi M, et al. Different influences of left ventricular remodeling on anterior and posterior mitral leaflet tethering. Circ J. 2012;76:2481–7.CrossRefGoogle Scholar
  6. 6.
    Kwan J, Shiota T, Agler DA, et al. Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation. Real-time three-dimensional echocardiography study. Circulation. 2003;107:1135–40.CrossRefGoogle Scholar
  7. 7.
    Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of ischemic mitral regurgitation: an experimental evaluation. Circulation. 1991;84:2167–80.CrossRefGoogle Scholar
  8. 8.
    Beaudoin J, Handschumacher MD, Zeng X, et al. Mitral valve enlargement in chronic aortic regurgitation as a compensatory mechanism to prevent functional mitral regurgitation in the dilated left ventricle. J Am Coll Cardiol. 2013;61:1809–16.CrossRefGoogle Scholar
  9. 9.
    Chaput M, Handschumacher MD, Tournoux F, et al. Mitral leaflet adaptation to ventricular remodeling: occurrence and adequacy in patients with functional mitral regurgitation. Circulation. 2008;118:845–52.CrossRefGoogle Scholar
  10. 10.
    Grayburn PA. New concepts in functional mitral regurgitation: it is not just a disease of the left ventricle. J Am Coll Cardiol. 2013;61:1817–9.CrossRefGoogle Scholar
  11. 11.
    Hickey MS, Smith LR, Muhlbaier LH, et al. Current prognosis of ischemic mitral regurgitation. Implications for future management. Circulation. 1988;78:I51–9.Google Scholar
  12. 12.
    Rossi A, Dini FL, Faggiano P, et al. Independent prognostic value of functional mitral regurgitation in patients with heart failure. A quantitative analysis of 1256 patients with ischaemic and non-ischaemic dilated cardiomyopathy. Heart. 2011;97:1675–80.CrossRefGoogle Scholar
  13. 13.
    Comin-Colet J, Sánchez-Corral MA, Manito N, et al. Effect of carvedilol therapy on functional mitral regurgitation, ventricular remodeling, and contractility in patients with heart failure due to left ventricular systolic dysfunction. Transplant Proc. 2002;34:177–8.CrossRefGoogle Scholar
  14. 14.
    Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:e57–185.CrossRefGoogle Scholar
  15. 15.
    Vahanian A, Alfieri O, Andreotti F, et al. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur J Cardiothorac Surg. 2012;42:S1–S44.CrossRefGoogle Scholar
  16. 16.
    Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147–239.CrossRefGoogle Scholar
  17. 17.
    Benjamin MM, Smith RL, Grayburn PA. Ischemic and functional mitral regurgitation in heart failure: natural history and treatment. Curr Cardiol Rep. 2014;16:517.CrossRefGoogle Scholar
  18. 18.
    Di Biase L, Auricchio A, Mohanty P, et al. Impact of cardiac resynchronization therapy on the severity of mitral regurgitation. Europace. 2011;13:829–38.CrossRefGoogle Scholar
  19. 19.
    Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011;364:1607–16.CrossRefGoogle Scholar
  20. 20.
    Kang DH, Sun BJ, Kim DH, et al. Percutaneous vs surgical revascularization in patients with ischemic mitral regurgitation. Circulation. 2011;124:S156–62.CrossRefGoogle Scholar
  21. 21.
    Acker MA, Parides MK, Perrault LP, et al. Mitral valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014;370:23–32.CrossRefGoogle Scholar
  22. 22.
    Yun KL, Sintek CF, Miller DC, et al. Randomized trial of partial versus complete chordal preservation methods of mitral valve replacement: A preliminary report. Circulation. 1999;100:II90–4.Google Scholar
  23. 23.
    Bolling SF, Deeb GM, Brunsting LA, Bach DS. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy. J Thorac Cardiovasc Surg. 1995;109:676–82.CrossRefGoogle Scholar
  24. 24.
    Geidel S, Lass M, Krause K, et al. Early and late results of restrictive mitral valve annuloplasty in 121 patients with cardiomyopathy and chronic mitral regurgitation. Thorac Cardiovasc Surg. 2008;56:262–8.CrossRefGoogle Scholar
  25. 25.
    Chen FY, Adams DH, Aranki SF, et al. Mitral valve repair in cardiomyopathy. Circulation. 1998;98:ll124–7.CrossRefGoogle Scholar
  26. 26.
    Calafiore AM, Gallina S, Di Mauro M, et al. Mitral valve procedure in dilated cardiomyopathy: repair or replacement? Ann Thorac Surg. 2001;71:1146–52.CrossRefGoogle Scholar
  27. 27.
    Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001;122:1125–41.CrossRefGoogle Scholar
  28. 28.
    Acker MA, Bolling S, Shemin R, et al. Mitral valve surgery in heart failure: insights from the Acorn Clinical Trial. J Thorac Cardiovasc Surg. 2006;132:568–77.CrossRefGoogle Scholar
  29. 29.
    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. J Am Coll Cardiol. 2005;45:381–7.CrossRefGoogle Scholar
  30. 30.
    Trichon BH, Glower DD, Shaw LK, et al. Survival after coronary revascularization, with and without mitral valve surgery, in patients with ischemic mitral regurgitation. Circulation. 2003;108:103–10.CrossRefGoogle Scholar
  31. 31.
    Fattouch K, Guccione F, Sampognaro R, et al. Point: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. J Thorac Cardiovasc Surg. 2009;138:278–85.CrossRefGoogle Scholar
  32. 32.
    Deja MA, Grayburn PA, Sun B, et al. Influence of mitral regurgitation repair on survival in the surgical treatment for ischemic heart failure trial. Circulation. 2012;125:2639–48.CrossRefGoogle Scholar
  33. 33.
    Chan KM, Punjabi PP, Flather M, et al. Coronary artery bypass surgery with or without mitral annuloplasty in moderate functional ischemic mitral regurgitation: final results of the Randomized Ischemic Mitral Evaluation (RIME) trial. Circulation. 2012;126:2502–10.CrossRefGoogle Scholar
  34. 34.
    Smith PK, Puskas JD, Ascheim DD, et al. Surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med. 2014;371:2178–88.CrossRefGoogle Scholar
  35. 35.
    Braun J, van de Veire NR, Klautz RJ, et al. Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure. Ann Thorac Surg. 2008;85:430–6.CrossRefGoogle Scholar
  36. 36.
    McGee EC, Gillinov AM, Blackstone EH, et al. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2004;128:916–24.CrossRefGoogle Scholar
  37. 37.
    Mihaljevic T, Lam BK, Rajeswaran J, et al. Impact of mitral valve annuloplasty combined with revascularization in patients with functional ischemic mitral regurgitation. J Am Coll Cardiol. 2007;49:2191–201.CrossRefGoogle Scholar
  38. 38.
    Magne J, Senechal M, Dumesnil JG, Pibarot P. Ischemic mitral regurgitation: a complex multifaceted disease. Cardiology. 2009;112:244–59.CrossRefGoogle Scholar
  39. 39.
    Goldstein D, Moskowitz AJ, Gelijns AC, et al. Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation. N Engl J Med. 2016;374:344–53.CrossRefGoogle Scholar
  40. 40.
    Hueb AC, Jatene FB, Moreira LF, Pomerantzeff PM, Kallás E, de Oliveira SA. Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: new insights from anatomic study. J Thorac Cardiovasc Surg. 2002;124:1216–24.CrossRefGoogle Scholar
  41. 41.
    Bach DS, Bolling SF. Early improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy. Am Heart J. 1995;129:1165–70.CrossRefGoogle Scholar
  42. 42.
    Bothe W, Kvitting JP, Stephens EH, et al. Effects of different annuloplasty ring types on mitral leaflet tenting area during acute myocardial ischemia. J Thorac Cardiovasc Surg. 2011;141:345–53.CrossRefGoogle Scholar
  43. 43.
    Lancellotti P, Moura L, Pierard LA, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: Mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr. 2010;11:307–32.CrossRefGoogle Scholar
  44. 44.
    Kron IL, Hung J, Overbey JR, et al. Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2015;149:752–61.CrossRefGoogle Scholar
  45. 45.
    Feldman T, Foster E, Glower D, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364:1395–406.CrossRefGoogle Scholar
  46. 46.
    Mauri L, Foster E, Glower DD, et al. Four-year results of a randomized controlled trial of percutaneous repair vs surgery for mitral regurgitation. J Am Coll Cardiol. 2013;62:317–28.CrossRefGoogle Scholar
  47. 47.
    Glower DD, Kar S, Trento A, et al. Percutaneous mitral valve repair for mitral regurgitation in high-risk patients: results of the EVEREST II study. J Am Coll Cardiol. 2014;64:172–81.CrossRefGoogle Scholar
  48. 48.
    Foster E, Kwan D, Feldman T, et al. Percutaneous mitral valve repair in the initial EVEREST cohort: evidence of reverse left ventricular remodeling. Circ Cardiovasc Imaging. 2013;6:522–30.CrossRefGoogle Scholar
  49. 49.
    Grayburn PA, Foster E, Sangli C, et al. Relationship between the magnitude of reduction in mitral regurgitation severity and left ventricular and left atrial reverse remodeling after MitraClip therapy. Circulation. 2013;128:1667–74.CrossRefGoogle Scholar
  50. 50.
    Auricchio A, Schillinger W, Meyer S, et al. PERMIT-CARE Investigators. Correction of mitral regurgitation in nonresponders to cardiac resynchronization therapy by MitraClip improves symptoms and promotes reverse remodeling. J Am Coll Cardiol. 2011;58:2183–9.CrossRefGoogle Scholar
  51. 51.
    Obadia JF, Messika-Zeitoun D, Leurent G, et al. MITRA-FR Investigators. Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation. N Engl J Med. 2018;379:2297–306.CrossRefGoogle Scholar
  52. 52.
    Stone GW, Lindenfeld J, Abraham WT, et al. COAPT Investigators. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. N Engl J Med. 2018;379:2307–18.CrossRefGoogle Scholar
  53. 53.
    A Clinical Evaluation of the Safety and Effectiveness of the MitraClip System in the Treatment of Clinically Significant Functional Mitral Regurgitation (Reshape-HF2). Available from: Identifier: NCT02444338. Accessed 23 Dec 2018.
  54. 54.
    Feldman T, Young A. Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 2014;63:2057–68.CrossRefGoogle Scholar
  55. 55.
    Sorini Dini C, Landi D, Meucci F, Di Mario C. Unexpected delayed complete atrioventricular block after Cardioband Implantation. Catheter Cardiovasc Interv. 2018;92:1201–4.CrossRefGoogle Scholar
  56. 56.
    Rogers JH, Boyd WD, Smith TWR, Ebner AA, Bolling SF. Combined MitraClip Edge-to-Edge Repair With Millipede IRIS Mitral Annuloplasty. JACC Cardiovasc Interv. 2018;11:323–4.CrossRefGoogle Scholar
  57. 57.
    Jorbenadze R, Schreieck J, Barthel C, et al. Percutaneous Edge-to-Edge Mitral Valve Repair Using the New MitraClip XTR System. JACC Cardiovasc Interv. 2018;11:e93–5.CrossRefGoogle Scholar
  58. 58.
    Regueiro A, Granada JF, Dagenais F, Rodes-Cabau J. Transcatheter mitral valve replacement: insights from early clinical experience and future challenges. J Am Coll Cardiol. 2017;69:2175–92.CrossRefGoogle Scholar
  59. 59.
    Lavall D, Hagendorff A, Schirmer SH, Bohm M, Borger MA, Laufs U. Mitral valve interventions in heart failure. ESC Heart Fail. 2018;5:552–61.CrossRefGoogle Scholar
  60. 60.
    Yoon SH, Whisenant BK, Bleiziffer S, et al. Transcatheter mitral valve replacement for degenerated bioprosthetic valves and failed annuloplasty rings. J Am Coll Cardiol. 2017;70:1121–31.CrossRefGoogle Scholar

Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2019

Authors and Affiliations

  1. 1.Department of Cardiac Surgery, Frankel Cardiovascular CenterUniversity of MichiganAnn ArborUSA

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