Chronic Ischemic Mitral Regurgitation

  • Jean-Louis VanoverscheldeEmail author
  • Gébrine El Khoury
  • Agnès Pasquet


Ischemic mitral regurgitation (MR) is mitral regurgitation due to complications of coronary artery disease, in particular myocardial infarction (MI), and not the fortuitous association of coronary artery disease with intrinsic valve disease such as degenerative, myxomatous, and connective tissue valvular disease, spontaneous ruptured chordae tendinae, and other causes of acute or chronic MR due to infection, inflammation, trauma, congenital abnormalities (including mitral valve (MV) prolapse), annular calcification, or tumor. Accordingly, the term ischemic MR should be restricted to chronic MR, occurring more than 2 weeks after MI and in the absence of structural MV disease. From a pathogenic point of view, it is a manifestation of postinfarction ventricular remodeling. The size, location, and transmurality of the MI sets in motion left ventricle (LV) remodeling that determines the severity, time course, and clinical manifestation of ischemic MR. The presentation develops insidiously over time in association with congestive heart failure.


Mitral Regurgitation Cardiac Resynchronization Therapy Posterior Leaflet Ischemic Mitral Regurgitation Regurgitant Volume 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Maisel AS, Gilpin EA, Klein L, Le Winter M, Henning H, Collins D. The murmur of papillary muscle dysfunction in acute myocardial infarction; clinical features and prognostic implications. Am Heart J. 1986;112:705-711.CrossRefPubMedGoogle Scholar
  2. 2.
    Barzilai B, Gessler C Jr, Pérez JE, Schaab C, Jaffe AS. Significance of Doppler-detected mitral regurgitation in acute myocardial infarction. Am J Cardiol. 1988;61:220-223.CrossRefPubMedGoogle Scholar
  3. 3.
    Lehmann KG, Francis CK, Dodge HT. Mitral regurgitation in early myocardial infarction: incidence, clinical detection, and prognostic implications: TIMI Study Group. Ann Intern Med. 1992;117:10-17.PubMedGoogle Scholar
  4. 4.
    Loperfido Loperfido F, Biasucci LM, Pennestri F, et al. Pulsed Doppler echocardiographic analysis of mitral regurgitation after myocardial infarction. Am J Cardiol. 1986;58:692-697.CrossRefGoogle Scholar
  5. 5.
    Tcheng JE, Jackman JD Jr, Nelson CL, et al. Outcome of patients sustaining acute ischemic mitral regurgitation during myocardial infarction. Ann Intern Med. 1992;117:18-24.PubMedGoogle Scholar
  6. 6.
    Hickey MS, Smith LR, Muhlbaier LH, et al. Current prognosis of ischemic mitral regurgitation. Implications for future management. Circulation. 1989;798:I51-I59.Google Scholar
  7. 7.
    Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik J. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation. 2001;103:1759-1764.PubMedGoogle Scholar
  8. 8.
    He S, Fontaine AA, Schwammenthal E, Yoganathan AP, Levine RA. Integrated mechanism for functional mitral regurgitation: leaflet restriction versus coapting force: in vitro studies. Circulation. 1997;96:1826-1834.PubMedGoogle Scholar
  9. 9.
    Roberts WC, Cohen LS. Left ventricular papillary muscles. Description of the normal and a survey of conditions causing them to be abnormal. Circulation. 1972;46:138-154.PubMedGoogle Scholar
  10. 10.
    Sharma SK, Seckler J, Israel DH, Borrico S, Ambrose JA. Clinical, angiographic and anatomic findings in acute severe ischemic mitral regurgitation. Am J Cardiol. 1992;70:277-280.CrossRefPubMedGoogle Scholar
  11. 11.
    Hendren WG, Nemec JJ, Lytle BW, et al. Mitral valve repair for ischemic mitral insufficiency. Ann Thorac Surg. 1991;52:1246-1251.CrossRefPubMedGoogle Scholar
  12. 12.
    Rankin JS, Feneley MP, Hickey MS, et al. A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 1988;95:165-177.PubMedGoogle Scholar
  13. 13.
    Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of ischemic mitral regurgitation. An experimental evaluation. Circulation. 1991;84:2167-2180.PubMedGoogle Scholar
  14. 14.
    Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation. 2005;112:745-758.CrossRefPubMedGoogle Scholar
  15. 15.
    Tenenbaum A, Leor J, Motro M, et al. Improved posterobasal segment function after thrombolysis is associated with decreased incidence of significant mitral regurgitation in a first inferior myocardial infarction. J Am Coll Cardiol. 1995;25:1558-1563.CrossRefPubMedGoogle Scholar
  16. 16.
    Aklog L, Filsoufi F, Flores KQ, et al. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation. 2001;104:I68-I75.CrossRefPubMedGoogle Scholar
  17. 17.
    Breithardt OA, Sinha AM, Schwammenthal E, et al. Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure. J Am Coll Cardiol. 2003;41:765-770.CrossRefPubMedGoogle Scholar
  18. 18.
    Kanzaki H, Bazaz R, Schwartzman D, Dohi K, Sade LE, Gorscan J 3rd. A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: insights from mechanical activation strain mapping. J Am Coll Cardiol. 2004;44:1619-1625.CrossRefPubMedGoogle Scholar
  19. 19.
    Levine HJ, Gaasch WH. Vasoactive drugs in chronic regurgitant lesions of the mitral and aortic valves. J Am Coll Cardiol. 1996;28:1083-1091.CrossRefPubMedGoogle Scholar
  20. 20.
    Heinle SK, Tice FD, Kisslo J. Effect of dobutamine stress echocardiography on mitral regurgitation. J Am Coll Cardiol. 1994;25:122-127.CrossRefGoogle Scholar
  21. 21.
    Kizilbash AM, Willett DL, Brickner ME, Heinle SK, Grayburn PA. Effects of afterload reduction on vena contracta width in mitral regurgitation. J Am Coll Cardiol. 1998;32:427-431.CrossRefPubMedGoogle Scholar
  22. 22.
    Godley RW, Wann LS, Rogers EW, Feigenbaum H, Weyman AE. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation. 1981;63:565-571.PubMedGoogle Scholar
  23. 23.
    Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik AJ. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction. A quantitative clinical study. Circulation. 2000;102:1400-1406.PubMedGoogle Scholar
  24. 24.
    Agricola E, Oppizzi M, Maisano F, et al. Echocardiographic classification of chronic ischemic mitral regurgitation caused by restricted motion according to tethering pattern. Eur J Echocardiogr. 2004;5:326-334.CrossRefPubMedGoogle Scholar
  25. 25.
    Agricola E, Oppizzi M, Pisani M, Meris A, Maisano F, Margonato A. Ischemic mitral regurgitation: mechanisms and echocardiographic classification. Eur J Echocardiogr. 2007;9:207-221.Google Scholar
  26. 26.
    Messas E, Guerrero JL, Handschumacher MD, et al. Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation. 2001;104:1958-1963.CrossRefPubMedGoogle Scholar
  27. 27.
    Salgo IS, Gorman JH 3rd, Gorman RC, et al. Effect of annular shape on leaflet curvature in reducing mitral leaflet stress. Circulation. 2002;106:711-717.CrossRefPubMedGoogle Scholar
  28. 28.
    Watanabe N, Ogasawara Y, Yamaura Y, et al. Mitral annulus flattens in ischemic mitral regurgitation: geometric differences between inferior and anterior myocardial infarction: a realtime 3-dimensional echocardiographic study. Circulation. 2005;112:I458-I1462.CrossRefPubMedGoogle Scholar
  29. 29.
    Ahmad RM, Gillinov AM, McCarthy PM, Blackstone EH, et al. Annular geometry and motion in human ischemic mitral regurgitation: novel assessment with three-dimensional echocardiography and computer reconstruction. Ann Thorac Surg. 2004;78:2063-2068.CrossRefPubMedGoogle Scholar
  30. 30.
    De Simone R, Wolf I, Mottl-Link S, et al. A clinical study of annular geometry and dynamics in patients with ischemic mitral regurgitation: new insights into asymmetrical ring annuloplasty. Eur J Cardiothorac Surg. 2006;29:355-361.CrossRefPubMedGoogle Scholar
  31. 31.
    Otsuji Y, Kumanohoso T, Yoshifuku S, et al. Isolated annular dilation does not usually cause important functional mitral regurgitation: comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy. J Am Coll Cardiol. 2002;39:1651-1656.CrossRefPubMedGoogle Scholar
  32. 32.
    He S, Lemmon JD Jr, Weston MW, Jensen MO, Levine RA, Yoganathan AP. Mitral valve compensation for annular dilatation: in vitro study into the mechanisms of functional mitral regurgitation with an adjustable annulus model. J Heart Valve Dis. 1999;8:294-302.PubMedGoogle Scholar
  33. 33.
    Lapu-Bula R, Robert A, Vancrayenest D, et al. Contribution of exercise-induced mitral regurgitation to exercise stroke volume and exercise capacity in patients with dilated cardiomyopathy. Circulation. 2002;106:1342-1348.CrossRefPubMedGoogle Scholar
  34. 34.
    Lancellotti P, Lebrun F, Pierard LA. Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol. 2003;42:1921-1928.CrossRefPubMedGoogle Scholar
  35. 35.
    Zoghbi WA, Enriquez-Sarano M, Foster E, et al. American Society of Echocardiography. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777-802.CrossRefPubMedGoogle Scholar
  36. 36.
    Matsumura Y, Fukuda S, Tran H, et al. Geometry of the proximal isovelocity surface area in mitral regurgitation by 3-dimensional color Doppler echocardiography: difference between functional mitral regurgitation and prolapse regurgitation. Am Heart J. 2008;155:231-238.CrossRefPubMedGoogle Scholar
  37. 37.
    Matsumura Y, Saracino G, Sugioka K, et al. Determination of regurgitant orifice area with the use of a new three-dimensional flow convergence geometric assumption in functional mitral regurgitation. J Am Soc Echocardiogr. 2008;21:1251-1256.CrossRefPubMedGoogle Scholar
  38. 38.
    Schwammenthal E, Chen C, Benning F, Block M, Breithardt G, Levine RA. Dynamics of mitral regurgitant flow and orifice area. Physiologic application of the proximal flow convergence method: clinical data and experimental testing. Circulation. 1994;90:307-322.PubMedGoogle Scholar
  39. 39.
    Buck T, Plicht B, Kahlert P, Schenk IM, Hunold P, Erbel R. Effect of dynamic flow rate and orifice area on mitral regurgitant stroke volume quantification using the proximal isovelocity surface area method. J Am Coll Cardiol. 2008;52: 767-778.CrossRefPubMedGoogle Scholar
  40. 40.
    Magne J, Pibarot P, Dagenais F, Hachicha Z, Dumesnil JG, Sénéchal M. Preoperative posterior leaflet angle accurately predicts outcome after restrictive mitral valve annuloplasty for ischemic mitral regurgitation. Circulation. 2007;115: 782-791.CrossRefPubMedGoogle Scholar
  41. 41.
    Watanabe N, Ogasawara Y, Yamaura Y, et al. Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography. J Am Coll Cardiol. 2005;45:763-769.CrossRefPubMedGoogle Scholar
  42. 42.
    Lancellotti P, Troisfontaines P, Toussaint AC, Pierard LA. Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction. Circulation. 2003;108:1713-1717.CrossRefPubMedGoogle Scholar
  43. 43.
    Vanoverschelde J-L, Pasquet A, Gerber BL, Melin LA. Principles of myocardial viability. Implications for echocardiography. In: Kisslo J, Nihoyannopoulos P, eds. Echocardiography. London: Springer; 2009:351-365.Google Scholar
  44. 44.
    de Waroux JB Le Polain, Pouleur AC, Vancraeynest D, et al. Early hazards of mitral ring annuloplasty in patients with moderate to severe ischemic mitral regurgitation undergoing coronary revascularization: the importance of preoperative myocardial viability. J Heart Valve Dis. 2009;18:35-43.Google Scholar
  45. 45.
    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;120:1474-1481.CrossRefPubMedGoogle Scholar
  46. 46.
    Flynn M, Curtin R, Nowicki ER, et al. Regional wall motion abnormalities and scarring in severe functional ischemic mitral regurgitation: A pilot cardiovascular magnetic resonance imaging study. J Thorac Cardiovasc Surg. 2009;137: 1063-1070.CrossRefPubMedGoogle Scholar
  47. 47.
    Stevenson LW, Bellil D, Grover-McKay M, et al. Effects of afterload reduction (diuretics and vasodilators) on left ventricular volume and mitral regurgitation in severe congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1987;60:654-658.CrossRefPubMedGoogle Scholar
  48. 48.
    Levine AB, Muller C, Levine TB. Effects of high-dose lisinopril-isosorbide dinitrate on severe mitral regurgitation and heart failure remodeling. Am J Cardiol. 1998;82:1299-1301.CrossRefPubMedGoogle Scholar
  49. 49.
    Bonet S, Agusti A, Arnau JM, et al. Beta-adrenergic blocking agents in heart failure: benefits of vasodilating and non-vasodilating agents according to patients’ characteristics: a meta-analysis of clinical trials. Arch Intern Med. 2000;160: 621-627.CrossRefPubMedGoogle Scholar
  50. 50.
    Lowes BD, Gill EA, Abraham WT, et al. Effects of carvedilol on left ventricular mass, chamber geometry, and mitral regurgitation in chronic heart failure. Am J Cardiol. 1999;83: 1201-1205.CrossRefPubMedGoogle Scholar
  51. 51.
    Capomolla S, Febo O, Gnemmi M, et al. Beta-blockade therapy in chronic heart failure: diastolic function and mitral regurgitation improvement by carvedilol. Am Heart J. 2000;139:596-608.CrossRefPubMedGoogle Scholar
  52. 52.
    Bolling SF, Pagani FD, Deeb GM, Bach DS. Intermediate term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg. 1998;115:381-386.CrossRefPubMedGoogle Scholar
  53. 53.
    Bax JJ, Braun J, Somer ST, et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation. 2004;110:II103-II108.PubMedGoogle Scholar
  54. 54.
    Braun J, Bax JJ, Versteegh MI, et al. Preoperative left ventricular dimensions predict reverse remodeling following restrictive mitral annuloplasty in ischemic mitral regurgitation. Eur J Cardiothorac Surg. 2005;27:847-853.CrossRefPubMedGoogle Scholar
  55. 55.
    Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation. 2004;110:II85-II90.CrossRefPubMedGoogle Scholar
  56. 56.
    Ereminiene E, Vaskelyte J, Benetis R, Stoskute N. Ischemic mitral valve repair: predictive significance of restrictive left ventricular diastolic filling. Echocardiography. 2005;22: 217-224.CrossRefPubMedGoogle Scholar
  57. 57.
    Kongsaerepong V, Shiota M, Gillinov AM, et al. Echocardiographic predictors of successful versus unsuccessful mitral valve repair in ischemic mitral regurgitation. Am J Cardiol. 2006;98:504-508.CrossRefPubMedGoogle Scholar
  58. 58.
    De Bonis M, Lapenna E, La Canna G, et al. Mitral valve repair for functional mitral regurgitation in end-stage dilated cardiomyopathy: role of the “edge-to-edge” technique. Circulation. 2005;112:I402-I408.PubMedGoogle Scholar
  59. 59.
    Akins CW, Hilgenberg AD, Buckley MJ, et al. Mitral valve reconstruction versus replacement for degenerative or ischemic mitral regurgitation. Ann Thorac Surg. 1994;58: 668-675.CrossRefPubMedGoogle Scholar
  60. 60.
    Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001;122:1125-1141.CrossRefPubMedGoogle Scholar
  61. 61.
    Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007;28:230-268.PubMedGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2010

Authors and Affiliations

  • Jean-Louis Vanoverschelde
    • 1
    Email author
  • Gébrine El Khoury
  • Agnès Pasquet
  1. 1.Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et CliniqueUniversité catholique de LouvainBrusselsBelgium

Personalised recommendations