ischemic mitral regurgitation can be defined as moderate to severe mitral leak precipitated by acute myocardial infarction .
valve repair is now the procedure of choice , but some cases can pose difficult anatomy .
most patients with ischemic mitral regurgitation have predominant annular dilatation at the posterior commissure and require only ring annuloplasty .
if papillary muscle elongation or rupture occurs , gore - tex artificial chordal replacement performs well . with ischemic mitral regurgitation accompanying posterior ventricular aneurysms ,
standard trans - atrial mitral repair provides the best results , with associated aneurysms being repaired concurrently .
surgical approaches and technical outcomes of mitral repair in ischemic mitral regurgitation are illustrated in 5 patients using operative images and echocardiograms .
each method is illustrated , including ring annuloplasty , pericardial leaflet augmentation , artificial chordal replacement , and ventricular aneurysm repair . using these techniques ,
virtually all ischemic mitral regurgitation can be repaired , with consequential patient benefits , even in the most complex anatomy .
ischemic mitral regurgitation has been shown to have better outcomes when managed with valve repair . using combinations of annular , leaflet , and chordal procedures
, even complex ischemic mitral regurgitation can undergo autologous reconstruction with excellent long - term results .
several divergent concepts currently exist about the prognosis and management of ischemic mitral regurgitation ( imr ) .
they range from  little can be done  to modify the dismal prognosis   - to mitral repair can  cure  the disorder ; from mitral repair should be  uniform    - to prosthetic replacement achieves  more certain  results .
one problem is that conclusions have been based on multiple different surgical approaches between centers , and also , statistical techniques often have been suboptimal .
thus , it is likely that outcome benefits did vary between institutions , with differences in surgery and other factors , accounting for the divergent conclusions .
the goal of this paper is to review repair techniques for imr used over the past 25 years at duke university medical center and to document observed outcome characteristics .
imr can be defined as mitral regurgitation precipitated by myocardial infarction , with essentially normal leaflet and chordal support .
imr usually is associated with myocardial necrosis , rather than reversible ischemia , and the infarction is usually inferior .
fact , mitral valve competence requires the integrated function of all five aspects of the valve - annulus , leaflets , chordae , papillary muscles , and ventricular wall . as defined in george burch s classic 1966  papillary muscle dysfunction  paper , most cases involve predominant posterior annular dilatation , but others experience leaflet tethering due to infarct expansion . rarely , papillary muscles can elongate or rupture , producing leaflet prolapse .
the common type of imr involves the posterior wall , usually is caused by right and/or circumflex coronary occlusion , produces moderate posterior - lateral left ventricular ( lv ) dysfunction , and usually will not reverse with revascularization alone . as described in the 1980 s , the decision to repair the valve should be based on the appearance of moderate or severe imr on the intra - operative transesophageal echo ( tee ) , sometimes with provocative volume loading from the pump before bypass . surgical techniques .
posterior annular dilatation is an important mechanism of  imr , and has been almost uniformly corrected in our practice with a true - sized full rigid or semi - rigid ring .
it has been shown that fixed reduction in anterior - posterior annular geometry is extremely important in this entity .
these patients often have minor leaflet abnormalities , such as fetal commissural cusps or clefts , predisposing them to opening up the valve with ischemic posterior annular dilatation .
occasionally , leaflets can be tethered by infarct expansion , contributing to lack of valve closure .
as langer showed , a posterior leaflet autologous pericardial patch can be used to compensate for the tethering , and this approach provides a large margin of safetylong - term , especially if further geometric changes occur . for leaflet prolapse due to elongated or ruptured papillary muscles , gore - tex artificial chords can be placed to a viable papillary muscle , adjusting chordal lengths after ring placement , as we have described .
the first patient is a 77 year old man , experiencing an acute circumflex infarct that produced acute moderate to severe mitral regurgitation ( mr ) and congestive heart failure . on tee ( figures 1 a , b )
, there is loss of valve coaptation at the posterior commissure ( red arrow ) , due to annular dilatation from a large posterior lateral infarct ( green arrow ) .
this produced the characteristic loss of coaptation area and a central mr jet , but both leaflets are at the annular plane and not tethered or prolapsed ( figure 1c ) .
after simple insertion of a full rigid ring , the valve is entirely competent ( figure 1d ) .
panel a is a short axis view of the left ventricle , showing an expanded posterior - lateral wall infarct ( green arrow ) .
panel b shows a gap in mitral coaptation at the posterior commissure during systole ( red arrow ) , producing a central regurgitant jet ( panel c ) , but the leaflets are at the annular plane .
this is the most common echocardiographic appearance of ischemic mitral regurgitation . in panel d ,
the second patient is a 55 year old obese diabetic who experienced a right coronary infarct and imr 6 months earlier that were treated with right coronary artery ( rca ) stenting . despite revascularization , imr and
she then developed an in - stent stenosis in the rca and an additional left anterior descending coronary artery ( lad ) lesion , and her ventricle showed residuals of the inferior infarct , with generalized dilatation .
there was loss of central mitral coaptation , due to annular dilatation , a hint of tenting and leaflet tethering ( figure 2a ) , and moderate to severe mr with a central jet ( figure 2 b).when the valve was inspected , however , the posterior leaflet seemed fine with good closure and minimal tethering on valve testing by ventricular distension with cold saline ( figure 2c ) . therefore ,
the valve is repaired by simple placement of a carpentier ring , with good recovery of competence , and no residual leak ( figure 2d ) .
so , most ischemic mitral regurgitation ( mr ) can be repaired with full ring annuloplasty alone , which achieves excellent results , with a documented 2% late reoperation rate ,   9% late moderate mr recurrence rate , and quite satisfactory echocardiographic results . clinical images in a patient with chronic ischemic mitral regurgitation .
panel a shows a hint of leaflet tethering ( green arrow ) , with both leaflets slightly below the annular plane .
in panel c , the posterior leaflet seems to coapt well ( red arrow ) with no evidence of tethering during valve testing with cold saline injection .
therefore , a simple ring annuloplasty was performed , and in panel d , the valve is completely competent .
the third patient is a frail elderly female presenting with an acute circumflex infarct and severe imr , treated initially with percutaneous coronary intervention ( pci ) . unlike the first 2 patients , she had prominent posterior leaflet tethering by echocardiography ( figure 3a ) , and severe lv dysfunction , mainly in the lateral wall due to the infarct . on emergency angiography , she had an occluded circumflex artery , but also lad and rca stenoses .
the circumflex was stented , but the imr persisted , the heart failure remained severe , and the ejection fraction continued at a 0.20 level . a magnetic resonance viability study was performed . in imr patients with low ejection fractions , we will operate if 2 of the 3 regions appear viable .
in fact , this patient seemed to have good residual myocardium everywhere . upon inspecting the valve ,
the right aspect of the posterior leaflet was tethered , and the posterior leaflet would nt coapt , even with saline distension . in figure 3b , one can see the posterior leaflet pulled down into the ventricle with tethering from infarct expansion .
a gluteraldehyde - fixed autologous pericardial patch was inserted into the posterior leaflet to compensate for the tethering , and the valve became nicely competent .
most of what is seen in figure 3c is patch , with the posterior leaflet moving down into the ventricle to become the entire coaptation area , and the valve is entirely competent ( figure 3d )
panel a shows both leaflets tented into the ventricle and not closing properly due to tethering ( green arrow ) .
direct inspection in panel b reveals taught posterior leaflet chords at the posterior commissure , inhibiting valve closure ( red arrow ) .
after insertion of an autologous pericardial patch into the posterior leaflet and placement of a carpentier ring ( panel c ) , the valve is entirely competent with a large coaptation area ( panel d ) .
the margin of safety provided by the patch may reduce later imr recurrence with further infarct expansion , or other problems .
a transthoracic echocardiogram , obtained 6 months postoperatively , showed good valve opening , and only trivial residual leak .
the fourth patient is a 57 year old man who had a major right coronary infarct , producing severe mr , a posterior lv aneurysm , and severe heart failure .
he also had lad disease , and - there was a large posterior wall aneurysm ( figure 4a ) .
the aneurysm was resected and closed primarily , approximating viable aneurysm edge to viable edge and removing all non - contractile scar . upon inspecting the valve , he had a chronically ruptured posterior papillary muscle at the posterior commissure , with severe prolapse that was not appreciated on the echo ( figure 4b ) .
a 2 - 0 gore - tex artificial chord was placed to a viable papillary muscle and stuffed into the ventricle for later retrieval . after ring placement ,
after repair , the valve was nicely competent ( figure 4c ) , with no residual leak ( figure 4d ) .
panel a is the left ventriculogram from a patient with severe ischemic mitral regurgitation and a large posterior wall aneurysm ( green arrow ) . in panel b
is shown an associated chronically ruptured papillary muscle producing prolapse of a posterior commissural cusp ( red arrow ) . in panel c
, an artificial chord has been placed to the commissural cusp , along with a carpentier ring , and the valve is completely competent ( panel d ) . combined chords and patches .
the last patient is a 61 year old man with a remote coronary bypass for an inferior infarction , and severe persistent imr due to simultaneous leaflet tethering and prolapse - a rare combination . in figure 5a
, one can see 2 separate jets of imr , with the posterior leaflet tethered down into the ventricle ( figure 5b ) and a segment of anterior leaflet prolapsing ( figure 5c ) .
thus , the patient had simultaneous posterior leaflet tethering from infarct expansion , and anterior leaflet prolapse due to papillary muscle elongation . with a patch to the posterior leaflet and an artificial chord to the anterior leaflet , the valve was completely competent with good leaflet position and no residual leak ( figure 5d ) .
this case illustrates that some varieties of imr can be quite complex , but with various combinations of full rings , pericardial patches , and artificial chords , the vast majority can be effectively repaired .
intraoperative transesophageal echo frames from an ischemic mitral regurgitation patient with both posterior leaflet tethering and anterior leaflet prolapse .
after repair of both lesions with a posterior leaflet pericardial patch and a chord to the anterior leaflet , the valve is fully competent ( panel d ) .
outcome characteristics of mitral repair.from several sources , it is now clear that the generally poor prognosis after mitral valve repair for imr ( a 56% 5-year unadjusted survival in our series ) is due primarily to the adverse patient profiles that are characteristic of this population , such as advanced age , numerous co - morbidities , and left ventricular dysfunction .
if these baseline risk factors are taken into account with a cox model ( figure 6 ) , valve repair seems to restore these patients to an adjusted survival that is similar to standard coronary bypass . also of note in this analysis , is the average 14% better risk - adjusted survival with valve repair , as compared to prosthetic valve replacement , which is consistent with most recent analyses .
survival curves over 15 years of follow - up adjusted with a cox proportional hazards model for differences in all important baseline patient characteristics .
the blue curve represents adjusted survival characteristics for 16,209 patients having coronary bypass alone without intraoperative transesophageal ( group 1 ) .
the red curve represents adjusted survival for 3,181 patients with mild - to - moderate intraoperative transesophageal treated with coronary bypass alone ( group 2a ) .
the green curve is adjusted survival for 416 patients with moderate - to - severe intraoperative transesophageal managed with mitral valve repair ( group 2b ) . and finally , the brown curve represents adjusted survival of 106 patients with moderate - to - severe intraoperative transesophageal receiving mitral valve replacement ( group 2c ) .
mitral repair for moderate - to - severe intraoperative transesophageal restored adjusted survival to levels equivalent to standard coronary bypass patients with similar risk profiles .
mitral valve replacement achieved an average 14% lower risk - adjusted survival over 15 years , as compared to valve repair .
in summary , the pathophysiology of ischemic mr can be complex , with aspects involving the annulus , leaflets , chords , papillary muscles , and ventricular wall .
based on our clinical experience , mitral valve repair should be the procedure of choice for moderate or worse imr , as encountered in the coronary disease population .
finally , effective mitral repair restores imr patients to a prognosis that is similar to standard coronary bypass , for a given patient s age and co - morbidities , and repair seems superior to valve replacement in all subsets .
 introductionischemic mitral regurgitation can be defined as moderate to severe mitral leak precipitated by acute myocardial infarction . 
 valve repair is now the procedure of choice , but some cases can pose difficult anatomy . 
 this review will illustrate current techniques for repairing complex ischemic mitral regurgitation.methodsmost patients with ischemic mitral regurgitation have predominant annular dilatation at the posterior commissure and require only ring annuloplasty . 
 full rigid rings are used preferentially . with leaflet tethering , adjunctive 
 autologous pericardial patches are effective in restoring leaflet coaptation . 
 if papillary muscle elongation or rupture occurs , gore - tex artificial chordal replacement performs well . with ischemic mitral regurgitation accompanying posterior ventricular aneurysms , 
 standard trans - atrial mitral repair provides the best results , with associated aneurysms being repaired concurrently.resultssurgical approaches and technical outcomes of mitral repair in ischemic mitral regurgitation are illustrated in 5 patients using operative images and echocardiograms . 
 each method is illustrated , including ring annuloplasty , pericardial leaflet augmentation , artificial chordal replacement , and ventricular aneurysm repair . using these techniques , 
 virtually all ischemic mitral regurgitation can be repaired , with consequential patient benefits , even in the most complex anatomy.conclusionsischemic mitral regurgitation has been shown to have better outcomes when managed with valve repair . 
 using combinations of annular , leaflet , and chordal procedures , even complex ischemic mitral regurgitation can undergo autologous reconstruction with excellent long - term results . 
Introduction
Methods
Results
Conclusions
Introduction
Conclusion