Mild Ischemic Mitral Regurgitation Research Articles

Abstract 10337: Early Adaptation of the Mitral Valve After St-Elevation Myocardial Infarction

Introduction: Ischemic mitral regurgitation (IMR) is associated with worse outcomes and higher mortality after myocardial infarction (MI). Clinical observations and experimental data have shown that mitral valve leaflets have the potential to enlarge over time to compensate left ventricular remodeling and prevent IMR. Previous animal studies have demonstrated that MI is associated with fibrotic changes in the mitral valve leaflets and prevent this adaptive compensation. However, the timing of mitral valve geometric changes are not well described. While previous data shows an increase in leaflet size at 6 and 12 months after MI, its short-term evolution after an ischemic event is not well documented. Methods: Twenty-two patients with ST-elevation myocardial infarction and initial left ventricular ejection fraction ≤ 45% were enrolled in Quebec Heart and Lung Institute. Participants had 3D transthoracic echocardiography (TTE) at baseline and 3 months, as well as cardiac magnetic resonance (CMR) at 3-month follow-up. Mitral valve leaflet size was measured from the 3D TTE using a custom software (Omni4D). CMR was used to derive left ventricular volumes, function and mitral regurgitant volume. Significant IMR was defined as a mitral regurgitant fraction ≥ 15% derived from the 3-month CMR. Results: Twenty-one of the 22 patients completed the imaging follow-up. Left ventricular ejection fraction at 3 months was 53 ± 10% (range from 37 to 69%). Eight patients (38%) had mild IMR at 3 months. Mitral valve surface area was significantly increased at 3 months compared with baseline for patients without IMR (10.96 ± 1.78 cm 2 vs 9.51 ± 1.62 cm 2 ; p = 0.001). Valve enlargement vs baseline was significantly greater in patients without IMR (+17 ± 13% vs -5 ± 4% for those with IMR at follow-up, p=0.0007). Conclusions: Mitral valvular surface increases within the first few months after MI, but not in all patients. Adequate valve enlargement seems related to the absence of IMR at 3 months.

C58. Management of Ellis Type V RV Branch Coronary Perforation Using Handmade Covered-stent: a case report

Abstract Coronary perforation is a rare but life-threatening complication of percutaneous coronary intervention (PCI) requiring urgent management including balloon inflation, thrombin, microcoils, fat embolization, autologous blood clots administration, heparin-reversing agent, covered-stent implantation, or surgery. We report a case of Ellis type V RV branch coronary artery perforation during PCI treated with a handmade covered-stent. A 69-year-old female presented with typical angina in three days. She was hemodynamically stable and no sign of congestion. Laboratory results showed leukocytosis, mild elevation of liver transaminase, elevated CK-MB level, mild hypoalbuminemia. ECG showed sinus rhythm with atrial bigeminy, late-onset inferoposterior and RV MI, and first-degree AV block. TTE revealed reduced LV systolic function (LVEF 45%), impaired LV relaxation, reduced RV function, marked LV hypokinetic in inferior, inferoseptal, apicoseptal, and inferolateral wall, and mild ischemic mitral regurgitation. DCA result showed 90 – 95% tubular stenosis in mid-LAD and total occlusion in proximal-RCA with grade V thrombus. She had an anomaly of RV branch angle that resembles the RCA so that the guidewire perforated the distal part of the RV branch artery. PCI was done using hydrophilic wire to distal RCA. Ellis type V perforation was found following multiple balloon inflation in RV branch. Perforation was managed with a handmade covered-stent using a Sirolimus-eluting stent with Tegaderm film. TIMI flow 3 was reached without thrombi or residual stenosis. In medical centers that have limited resources, handmade covered-stents can be used as an option after unsuccessful balloon inflation trial.

C58. Management of Ellis Type V RV Branch Coronary Perforation Using Handmade Covered-stent: a case report

Abstract Coronary perforation is a rare but life-threatening complication of percutaneous coronary intervention (PCI) requiring urgent management including balloon inflation, thrombin, microcoils, fat embolization, autologous blood clots administration, heparin-reversing agent, covered-stent implantation, or surgery. We report a case of Ellis type V RV branch coronary artery perforation during PCI treated with a handmade covered-stent. A 69-year-old female presented with typical angina in three days. She was hemodynamically stable and no sign of congestion. Laboratory results showed leukocytosis, mild elevation of liver transaminase, elevated CK-MB level, mild hypoalbuminemia. ECG showed sinus rhythm with atrial bigeminy, late-onset inferoposterior and RV MI, and first-degree AV block. TTE revealed reduced LV systolic function (LVEF 45%), impaired LV relaxation, reduced RV function, marked LV hypokinetic in inferior, inferoseptal, apicoseptal, and inferolateral wall, and mild ischemic mitral regurgitation. DCA result showed 90 – 95% tubular stenosis in mid-LAD and total occlusion in proximal-RCA with grade V thrombus. She had an anomaly of RV branch angle that resembles the RCA so that the guidewire perforated the distal part of the RV branch artery. PCI was done using hydrophilic wire to distal RCA. Ellis type V perforation was found following multiple balloon inflation in RV branch. Perforation was managed with a handmade covered-stent using a Sirolimus-eluting stent with Tegaderm film. TIMI flow 3 was reached without thrombi or residual stenosis. In medical centers that have limited resources, handmade covered-stents can be used as an option after unsuccessful balloon inflation trial.

Nomogram Predicts Improvement of Ischemic Mitral Regurgitation After Coronary Artery Bypass Grafting

BackgroundDeveloping a nomogram to predict improvement in moderate ischemic mitral regurgitation (IMR) after coronary artery bypass grafting (CABG) is in need. MethodsWe retrospectively collected data from 112 patients with prior myocardial infarction and moderate IMR undergoing CABG between 2010 and 2018. Patients were divided into 2 groups based on IMR degree 1 year after CABG as follows: Improved Group with no or mild IMR (n = 54) and Failure Group with moderate or severe IMR (n = 58). To determine the predictors of postoperative IMR improvement, preoperative clinical and echocardiographic data were compared, and a nomogram was formulated based on all independent predictors. Discriminative ability, calibration, and clinical usefulness of the prediction model were assessed. ResultsIndependent predictors of IMR improvement after CABG constructing the nomogram included duration between infarction and operation, posterior-inferior to left ventricular volume ratio, maximum difference of the time to reach minimum systolic volume of 16 segments, P3 leaflet tethering angle, and annular nonplanar angle. The nomogram exhibited well-fitted calibration curves and excellent discriminative ability. The area under the receiver operating characteristic curve was 0.974. Patients with a score >236 demonstrated a high probability of IMR improvement (sensitivity, 90.7%; specificity, 93.1%). Patients in the Improved Group demonstrated greater actuarial survival rates than those in the Failure Group. ConclusionsThe nomogram combining 5 preoperative clinical and echocardiographic predictors provides an accurate preoperative estimation of moderate IMR improvement after surgery, with excellent discriminative ability. Based on this nomogram, patients with a higher score have predicted higher probabilities of IMR improvement.

The association between myocardial scar and the response of moderate ischemic mitral regurgitation to isolated coronary artery bypass grafting.

BackgroundThe factors that associated with the response of moderate ischemic mitral regurgitation (IMR) to isolated coronary artery bypass grafting (CABG) remain unclear. This study aims to evaluate whether left ventricular (LV) myocardial scar assessed by cardiovascular magnetic resonance (CMR) is associated with the outcome of moderate IMR after isolated CABG.MethodsForty-six patients with coronary artery disease (CAD) and moderate IMR who underwent isolated CABG between January 2014 and February 2019 in Anzhen Hospital Affiliated to Capital Medical University were enrolled in this case-control study. All patients underwent CMR and echocardiography before surgery. Patients were classified into two groups according to the severity of IMR 1 year after CABG: an improved group (no or mild IMR) and an unimproved group (moderate or severe IMR). Univariate and multivariate logistic regression analyses were used to assess the association between individual variables and unimproved IMR at 1-year post-CABG.ResultsCompared to patients in the improved group, the patients in the unimproved group had a significantly greater amount of LV myocardial scar (18.0%±9.5% vs. 30.8%±11.2%, P<0.001). In the multiple logistic regression model, after adjustment for age, sex, and body mass index, only LV myocardial scar (OR: 0.89, 95% CI: 0.83–0.96, P=0.001) was independently associated with unimproved IMR after isolated CABG. Furthermore, there was no difference in the 3-year overall survival rates between the two groups (92.3% vs. 90.3%, P=0.46). In addition, patients in the unimproved group had a higher New York Heart Association (NYHA) classification (P=0.01) and more major adverse cardiac events such as MI, angina pectoris, and readmission for heart failure (P=0.03).ConclusionsA greater amount of preoperative LV myocardial scar was associated with unimproved moderate IMR after isolated CABG. Measuring preoperative LV myocardial scar is helpful to predict post-operative outcome and determine optimal surgery in patients with moderate IMR.

The impact of mild ischemic mitral regurgitation in the occurrence of congestive heart failure

Ischemic mitral regurgitation (IMR) is a common complication of myocardial infarction, leading to left ventricular (LV) dysfunction and remodeling. Its presence is associated with an increased risk for death and heart failure. The aim of this study was to evaluate the impact of a mild degree (effective regurgitant orifice area < 20 mm 2 ) of IMR on heart failure (HF). This is a retrospective, study including 210 patients who had been hospitalized in a cardiology intensive care unit for myocardial infarction from September 2018 to March 2020, 36 patients with mild IMR were compared to 40 patients without IMR (controls), measuring LV volumes, ejection-fraction, and the degree of mitral regurgitation and incidence of HF events. The main age was 59.3 ± 7.02 sex ratio: 2.86 (74.1% male, 25.9% female) 32.3% of patients had de novo heart failure of which 29.2% with mild IMR. Patients with IMR had a significantly higher incidence of HF than controls (72% vs. 34%, P = 0.001), a significant increase in LV end-diastolic and end-systolic volumes, ( P = 0.004) and lower ejection-fractions ( P = 0.0002). The culprit artery was left anterior descending artery in 54.4%. The presence of IMR, even mild in degree, has an impact on the progression of the post-infarction ventricular dysfunction and a higher rate of HF.

Prior angina reduces ıschemic mitral regurgitation in patients with ST-Elevation myocardial ınfarction, role of ıschemic preconditioning.

Mitral regurgitationmay develop due to left ventricular (LV) remodeling within 3months following acute myocardial infarction (AMI) and is called ischemic mitral regurgitation (IMR).Ischemic preconditioning (IPC) has been reported as the most important mechanism of the association between prior angina and the favorable outcome. The aim of this study was to investigate the effect of prior angina on the development and severity of IMR at 3rdmonth in patients with ST elevation MI (STEMI). Fourty five (45) patients admitted with STEMI and at least mild IMR, revascularized by PCI were enrolled. According topresence of prior angina within 72h before STEMI, patients were then divided into two groups as angina (+) (n:26; 58%) and angina (-) (n:19; 42%). All patients underwent 2D transthoracic echocardiography at1st, 3rddays and 3rdmonth. IMR was evaluated byproximal isovelocity surface area (PISA) method: PISA radius (PISA-r), effective regurgitant orifice area (EROA), regurgitant volume (Rvol). LV ejection fraction (EF %) was calculated by Simpson's method. High sensitive troponin T (hs-TnT), creatine phosphokinase myocardial band (CK-MB) and N-terminal pro-brain natriuretic peptid (NTpro-BNP) levels were compared between two groups. Although PISA-r, EROA and Rvol were similar in both groups at 1stand 3rddays, all were significantly decreased (p = 0.012, p = 0.007, p = 0.011, respectively) and EF was significantly increased (p< 0.001) in angina (+) group at 3rdmonth. NTpro-BNP and hs-TnT levels at 1stday and 3rdmonth were similar, however CK-MB level at 3rdmonth was found to be significantly lower in the angina (+) group (p = 0.034). At the end of the 3rdmonth, it was observed that the severity of IMR evaluated by PISA method was decreased and EF increased significantly in patients who defined angina within 72h prior to STEMI, suggesting a relation withIPC.

Predictors of moderate to severe ischemic mitral regurgitation after myocardial infarction: a cardiac magnetic resonance study.

The purpose of this study is to explore the predictors of moderate to severe ischemic mitral regurgitation (IMR) after myocardial infarction with cardiovascular magnetic resonance (CMR). From January 2016 to September 2018, 109 patients (mean age 60 ± 8years) with IMR were studied retrospectively. All patients underwent CMR-cine with True-FISP sequence and late gadolinium enhancement (LGE) with a phase-sensitive inversion recovery sequence. The presence of papillary muscle infarction (PMI), global left ventricular (LV) infarcted extent, LV functional parameters, and LV myocardial strain were assessed. Univariate and multivariate analyses were performed to identify factors in the development of moderate to severe IMR. Mild IMR was present in 61 patients (56%), and moderate to severe IMR was present in 48 patients (44%). PMI was identified in 22 patients (20.1%); 14 of them (63.63%) showed a moderate or severe IMR. Global LV infarcted extent was increased in patients with moderate to severe IMR (p< 0.001). LV functional parameters of patients with moderate to severe IMR were statistically different from those of the patients with mild IMR (all p< 0.001), except the LV SV index (p= 0.142) and LV CI (p= 0.447). The global longitudinal strain (GLS), regional radial strain (RS), and circumferential strain (CS) of the moderate-to-severe IMR group were significantly decreased compared with those of the mild IMR group (p< 0.05). In multivariable analyses, age (OR = 1.11; p= 0.001), global LV infarct extent (OR = 1.14; p= 0.000), and GLS (OR = 1.31; p= 0.000) were associated with moderate-to-severe chronic IMR. The incidence of PMI was higher in patients with moderate-to-severe IMR. The extent of global LV infarcted extent and GLS were independent predictors of moderate-to-severe IMR. • Cardiovascular magnetic resonance late gadolinium enhancement and feature-tracking imaging provide reliable information on LV function, myocardial viability, and papillary muscle morphology. • Papillary muscle infarction is not an independent predictor of moderate-to-severe IMR. • The extent of global LV infarction and LV global longitudinal strain were independent predictors of moderate-to-severe chronic IMR.

Mild Ischemic Mitral Regurgitation: Is Revascularization Enough for Every Patient?

The progress of mild ischemic mitral regurgitation (MR) after isolated coronary artery bypass is not clear. We aimed to determine the proportion of patients with mild ischemic MR undergoing isolated coronary artery bypass grafting (CABG) presenting with regression of or persistent MR one year after CABG and to identify the significantly different echocardiographic variables between regressing and persistent MR. Sixty-three patients with preoperative mild ischemic MR were categorized into an MR- regression or an MR-persistence group one year after isolated CABG. The echocardiographic indices, indicating mitral leaflet configuration and remodeling of the left ventricle (LV), were measured before and one year after the surgery. One year after CABG, MR regressed in 60% (38/63) and persisted in 40% (25/63) of the patients. The left ventricular diameter, volume, and sphericity and anteroposterior diameter of the mitral annulus improved only in the MR-regression group, while the ejection fraction improved in both groups (47.7% ± 12.4% from 40.1% ± 11.3%, P < .001 in the regression group and 43.2% ± 14.0% from 39.3% ± 11.6%, P = .035 in the persistence group). A >15% decrease in the LV end-systolic volume was noted more frequently in the MR-regression group (60.5% versus 30%, P = .027). The leaflet angle did not show asymmetry or significant changes in both groups. Isolated CABG improved mild MR in most patients with mild ischemic MR. These patients showed greater reverse remodeling after revascularization than the patients with persistent MR after isolated CABG. Additional tests, which can predict LV reverse remodeling, are needed to predict persistent MR.

Ischemic Mitral Regurgitation: Echocardiographic Algorithm, the Place of Three-Dimensional Transesophageal Echocardiography

Objective Identify the diagnostic markers of the severe MV changes in patients with ischemic mitral regurgitation (IMR) and suggest a modification of the echocardiography (EchoCG) algorithm.Materials and Methods A two-stage examination of 65 patients with mild (n=22), moderate (n=22), and severe (n=21) IMR was performed using two-dimensional (2D) transthoracic EchoCG with dopplerography, 2D and three-dimensional (3D) transesophageal EchoCG (TEE). 4D MV-Assessment in off-line mode was made in TomTec Imaging Systems GmbH, Germany. Statistical analysis (SAS 9.4) included Student's t-test, Kruskal-Wallis method, Pearson correlation, multivariate regression analysis, and ROC-analysis.Results According to 3D TEE the significant changes in MV annulus, leaflets and tenting are detected. 3D parameters of MV geometry are related to IMR severity, left ventricle (LV) remodeling (global and regional), and they are different in symmetric and asymmetric variants. In symmetric variant MV reconstruction is correlated with LV dilatation and contractility decrease, in asymmetric variant it's correlated with regional remodeling parameters. Severe IMR is characterized by a decrease in MV annulus displacement (27,0±6,6 mm/s versus 32,4±10,8 mm/s in mild IMR; р&lt;0,05), tenting volume fraction (32,5±14,8% versus 56,2±16,8% in mild IMR; p&lt;0,05), and annulus area fraction (4,7±2,7% versus 6,6±4,5% in mild IMR; р&lt;0,05). Vena contracta width (VCW), Proximal Isovelocity Surface Area (PISA) radius, Effective Regurgitant Orifice Area (EROA), Regurgitant Volume (Rvol), LV end systolic dimension (LV ESD), and central large jet &gt;50% of left atrium (LA) area have a predictive value in the diagnosis of MV geometry severe changes. If thresholds are reached these 2D TTE parameters can be used as indications for the 3D TEE.Conclusion 3D TEE allows for detailed assessment of MV geometry and function depended on IMR severity and variant. To make decision of MV surgery 3D TEE is recommended if the following indicators are presented: (1) VCW ≥0,7 cm; PISA radius ≥1,0 cm; central large jet &gt;50% of LA area; LV ESD ≥4,0 cm; (2) VCW ≥0,6 cm; PISA radius = 0,6-0,99 cm; EROA ≥0,3 cm2; RVol≥45 cm; IMR eccentric jet + IMR elliptical orifice.

Assessment of left atrial function in elderly patients with ischemic mitral regurgitation by real-time three-dimensional speckle tracking imaging

Objective To assess left atrial(LA)function by evaluating changes of LA wall movement and volume detected by real-time three-dimensional speckle tracking imaging(RT3D-STI)in elderly patients with ischemic mitral regurgitation(IMR). Methods Eighty-six elderly patients with coronary heart disease(CHD)were enrolled in this study.According to whether or not to have IMR, the patients were divided into the pure CHD group(n=32)and the CHD-induced ischemic mitral regurgitation(IMR)group(n=54, including 20 cases of mild IMR, 18 cases of moderate IMR and 16 cases of severe IMR). Thirty-two healthy elderly volunteers were considered as control group.RT3D-STI was used to evaluate the global atrial longitudinal strain(GLS), global circumferential strain(GCS), global radial strain(GRS)and LA maximal, minimal and pre-systolic volumes(LAVmax, LAVmin, and LAVp). LA ejection fraction(LAEF), LA passive ejection fraction(LApEF)and LA active ejection fraction(LAaEF)were calculated.The relationship of LA volume changes and myocardial strain with LA function was analyzed. Results The left ventricular ejection fraction(LVEF)and LAEF were reduced in CHD group and IMR group as compared with the control group, and were lower in IMR group than in CHD group(P<0.05). Compared with the control group, the LAVmin was increased, and the LAaEF was decreased in the IMR group(P<0.05). Compared with the control group, the GLS, GCS, GRS were declined in the CHD and IMR groups, and were lower in IMR group than in control group(P<0.05). Along with the increased severity of regurgitation, GLS, GCS, and GRS were decreased in varying degrees.The standard deviations of time to peak longitudinal strains(TLS-SD), of time to peak circumferential strains(TCS-SD), and of time to peak radial strain(TRS-SD)rose in the IMR group as compared with the control group(P<0.05). The myocardial motion indicators(GLS, GCS, GRS)had a quite strong correlation with LAEF in the CHD and IMR groups(CHD group: r=-0.745, -0.718 and 0.627, P=0.006, 0.007 and 0.009; IMR group: r=-0.785, -0.781, 0.643, P=0.006, 0.007 and 0.008). The receiver operating characteristic(ROC)curves analysis showed that the sensitivity and specificity of TLS-SD, TCS-SD and TRS-SD were 89.7% and 81.8%, 78.6% and 84.8%, 85.7% and 72.1%, respectively in the evaluation of LA function changes. Conclusions RT3D-STI can precisely and objectively assess the LA function changes by measuring the volume changes and tracing the myocardial motion in elderly IMR patients. Key words: Coronary disease; Mitral valve insufficiency; Echocardiography, three-dimensional; Atrail function, left

P762 Preserved mitral apparatus dynamics predict the improvement of acute ischemic mitral regurgitation: four-dimensional quantitative echocardiographic study

Abstract Background We sought to evaluate the predictive value of acute stage mitral apparatus geometry and dynamics for the reduction of ischemic mitral regurgitation (IMR) in the remote phase after successful primary percutaneous coronary intervention (pPCI) by using real-time 3D-transthoracic echocardiography (3D-TTE). Methods We performed 2D and 3D-TTE in consecutive 44 first acute MI patients with more than mild IMR within 3 days after successful pPCI. 3DTTE of left ventricle (LV) volumes and mitral apparatus dynamics through the cardiac cycle were quantified offline. We compared the 3D geometric and dynamic parameters in the acute phase between 1)20 remained MR group and 2)24 improved MR group in 6-to-12 months after MI onset. Results Ejection fraction (EF) was preserved in the improved MR group compared to the remained MR group (49.0 ± 11.2 vs. 56.5 ± 7.0%, p = 0.013). Mitral valve annulus area, leaflet tenting length and papillary muscles spatial position had no significant difference between the two groups (all p &amp;gt; 0.05) throughout cardiac cycle. In contrast, mitral annulus saddle shape was preserved in the improved MR group than the remained MR group (p = 0.010) and annular area changed dynamically through early- to late-systole in the improved MR group (phasic p = 0.017) despite it was adynamic in remained MR group (phasic p = 0.201). Conclusions: IMR improvement in the remote phase after AMI associated with preserved EF, mitral annulus saddle shape and dynamics during systole in the acute phase of MI. 4D dynamics of the mitral apparatus can be clinically useful predictor of the improvement in acute IMR and may contribute to the clinical decision making including surgical or percutaneous intervention for IMR.

P292 The risk of adverse outcome with ischemic mitral regurgitation at 6-month after myocardial infarction: possible benefit of early intervention by transcatheter mitral-valve repair

Abstract Background The latest study has demonstrated the better outcomes of transcatheter mitral-valve repair in patients with decompensated heart failure (HF) and left ventricular (LV) dysfunction. However, it is unknown whether earlier intervention for mitral regurgitation (MR) can improve the outcome of myocardial infarction (MI). Purpose The aim of this study was to investigate the prognostic value of ischemic MR (IMR) at 6-month after MI for the later incidence of HF and death. Methods We retrospectively examined 723 MI patients who were admitted to our hospital. 95.5% of the patients were treated by primary coronary intervention. Patients were clinically followed-up at 6-month after the onset of MI, and divided into 3 groups according to the degree of IMR, i.e. No/Trivial IMR group (n = 528), Mild IMR group (n= 154) and ≥Moderate IMR group (n= 41). We compared the later incidence of hospitalization for HF and all-cause death at 3-year for each group. Results The studied population had preserved ejection fraction (EF) (56.9 ± 10.7%, average) and mostly asymptomatic at 6-month after MI. All-cause mortality within 3-year was higher in patients with ≥Moderate IMR (p &amp;lt; 0.001), and the incidence of hospitalization for HF was significantly higher depends on the degree of IMR at 6-month (p &amp;lt; 0.001). Multivariate analysis showed EF and the degree of IMR were the independent predictor for the hospitalization for HF. Conclusions IMR at 6-month after MI was associated with the later adverse events despite relatively preserved LV contraction without heart failure symptoms at the index examination. Early intervention for IMR potentially benefit for the better outcome. Abstract P292 Figure. Caplan-Meier estimates on adverse events

Ischemic mitral regurgitation: modern evidence based echocardiography diagnosis, quantification and risks stratification review

Ischemic mitral regurgitation (IMR) is a frequent complication in the patients after acute myocardial infarction (AMI) or in ischemic cardiomyopathy (ICM), associated with significant prognosis worsening. Mitral valve (MV) involvement may be primary (organic MR) or secondary (functional MR). Primary MR develops because of mitral subvalvular apparatus rupture as an AMI complication. Secondary IMR develops in the conditions of normal MV cusps and chords structure because of balance impairment between MV closure and tension forces secondary to left ventricle (LV) geometry alterations. According to evidence data both scenarios of IMR are associated with at least one major coronary artery critical stenosis (&gt;70%). Secondary IMR is the most frequent consequence of ischemic cardiomyopathy. IMR diagnosis is associated with elevated patients mortality compared to those without it. It has been shown, that survival within patients with IMR after AMI down to 40% in case of moderate-to-severe IMR, compared to 62% in the patients with mild IMR or 84% in the patients without IMR at all. Pathophysiological mechanisms of IMR are not fully understood, but it is well known, that IMR is a complex entity, having left chambers, especially left ventricle (LV) remodeling as a key cause. Echocardiography (EchoCG) significantly contributes to understanding the underlying mechanisms of IMR. The aim of this review is to summarize modern evidence based data about IMR mechanisms and analysis of contemporary EchoCG indices for diagnosis, evaluation and risks stratification in the patients with IMR. IMR develops in approximately 20% of patients after AMI with increasing occurrence over past years, significantly influencing patients’ prognosis. IMR is a complex and dynamic entity, where LV remodeling is the main factor of MV dysfunction. EchoCG plays the clue role in IMR diagnosis giving the detailed information about its mechanisms and severity grading. Comprehensive EchoCG in the patients with coronary arteries disease (CAD) allows a better and comprehensive approach in risks stratification and optimal surgical IMR treatment planning.

Ischemic Mitral Regurgitation: Current Understanding and Surgical Options.

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.

Three-dimensional mitral valve structure in predicting moderate ischemic mitral regurgitation improvement after coronary artery bypass grafting

ObjectiveFocusing on 3-dimensional mitral valve structure, this study investigated predictors for moderate ischemic mitral regurgitation (IMR) improvement after off-pump coronary artery bypass grafting (OPCAB). MethodsThis study included 143 patients (age 67.6 ± 7.6 years, 32.9% female) with previous myocardial infarction and moderate IMR undergoing OPCAB. Preoperative 3-dimensional echocardiographic data were analyzed, focusing on mitral annular geometry and leaflet tethering model. Patients were grouped according to IMR at 1-year postoperative follow-up into improved (n = 65), with no or mild IMR, and failure (n = 70), with moderate or severe IMR, groups. Groups were compared to identify predictors of IMR improvement after OPCAB. ResultsEight patients died within 1 year. At 1 postoperative year, improved group included 65 patients; failure group included 70. Improved group had less preoperative annular flattening (smaller nonplanar angle) and segmental leaflet tethering (smaller A3, P1, P2, and P3 tethering angles) than failure group. Nonplanar angle (P < .001) and P3 tethering angle (P < .001) were independent predictors of moderate IMR improvement after OPCAB. Receiver operator characteristic curves defined P3 tethering angle of 28.8° (sensitivity of 78.6%, specificity of 84.6%) and nonplanar angle of 158.1° (sensitivity, 64.3% and specificity of 86.2%) as the cutoff values. ConclusionsPreoperative moderate IMR can be improved by OPCAB in selected patients. Less annular flattening and P3 leaflet tethering may predict improvement of moderate IMR after OPCAB, suggesting that the annular nonplanar saddle shape and less leaflet tethering toward P3 segment are important for the prognosis of moderate IMR.

DETERMINATION OF DELAY FREQUENCY IN REFERRAL AND ITS RELATED FACTORS IN PATIENTS WITH STEMI, WHO REFERRED TO IMAM REZA HOSPITAL EMERGENCY IN 93-92

Objectives & ( hypothesis OR questions) : Ischemic mitral regurgitation (IMR) is a major source of morbidity and mortality of myocardial infarction. Although mitral valve repair has become recently popularized for the treatment of IMR, select patients may derive benefits from replacement. The purpose of this study is to describe current surgical options for IMR and to discuss when mitral valve repair (MVR) by KAY method may be favored over mitral valve replacement. Materials & Methods: This clinical study was conducted from 28 may 2014 to 2016-05-28 ,in cardiac surgery ward of Imam Reza Hospital of Mashhad University of Medical Sciences retrospectively. All of patients with ischemic mitral regurgitation (moderate or severe) who needs CABG planned CABG +Mitral Repair and KAY method had been chosen .and all patients follow –up for One year by admission and echocardiography in day of discharge -3 months and 1 year ago. Operation and echocardiography was done by same cardiac surgeon and cardiologist. Results: We found 12 patients (male=5,femal=8) that operated by CABG AND KAY METHOD ,IN 75% of them was a history of previous myocardial infarction and in remainder there was acute ischemia of myocardium. In 91/7% patients there was inferior myocardial infarction and dominant coronary vessel was RCA.ALL of patient had significant MR that resolved in all of them (p-value. (0.05> there isn’t any preoperative and post operative mortality. The main time of CPB was 150 minute and in t2 test revealed 10% increased ejection fraction of left ventricle (p value <0/0005).no further postoperative reported in 1 year follow-up patients. Conclusion :Although surgical CABG alone may benefit patients with mild–moderate IMR, most surgeons advocate the performance of CABG in combination with either mitral valve repair or replacement. In the current era, and in Iran mitral valve repair specially KAY method has proven to offer improved short-term and long-term survival, decreased valve-related morbidity, and improved left ventricular function and it is cost effective procedure. Future randomized, prospective clinical trials are needed to compare this surgical technique.

Predictors of moderate ischemic mitral regurgitation improvement after off-pump coronary artery bypass

ObjectiveThe aim of this study was to explore the predictors of improvement of moderate ischemic mitral regurgitation after off-pump coronary artery bypass grafting. MethodsA prospective study was performed among 109 patients (aged 66.6 ± 8.6 years, 34.6% were female) with prior myocardial infarction and moderate ischemic mitral regurgitation undergoing off-pump coronary artery bypass grafting. Preoperative and follow-up clinical characteristics and echocardiography data were analyzed, focusing on left ventricular global/regional remodeling and function. Patients were grouped by postoperative ischemic mitral regurgitation at 1 year postoperatively: the improved group with no or mild ischemic mitral regurgitation and the failure group with moderate or severe ischemic mitral regurgitation. Data were compared between the 2 groups to explore the predictors of ischemic mitral regurgitation improvement after off-pump coronary artery bypass grafting. ResultsFive patients died within 1 year and were excluded. At the 1-year follow-up, there were 55 patients in the improved group and 49 patients in the failure group. Before surgery, the improved group had smaller left ventricular end-systolic volume, greater left ventricular ejection fraction, greater posterior-inferior volume ratio, and earlier operation timing after infarction than the failure group. Posterior-inferior volume ratio (P < .001), ejection fraction (P = .003), and duration between infarction and operation (P < .001) were independent predictors of preoperative moderate ischemic mitral regurgitation improvement. ConclusionsIn selected patients, preoperative moderate ischemic mitral regurgitation was relieved by off-pump coronary artery bypass grafting. Greater ejection fraction, greater posterior-inferior volume ratio, and early operation timing after infarction may predict the improvement of moderate ischemic mitral regurgitation after off-pump coronary artery bypass grafting, suggesting that posterior-inferior regional remodeling, reserved ventricular function, and early revascularization are important to the outcome.

Role of coaptation imaging of mitral valve on ischemic mitral regurgitation by real-time three-dimensional transesophageal echocardiography

Objective To explore the impact of morphological changes of mitral valve coaptation on ischemic mitral regurgitation (IMR), and observe coaptation image of mitral valve in systole in patients with IMR by using real-time three-dimensional transesophageal echocardiography (RT3D-TEE). Methods RT3D-TEE was performed on 112 patients with IMR and 38 patients without MR as the control. Patients with IMR were divided into group of mild IMR (n=46), group of moderate IMR (n=45) and group of severe IMR (n=21), according to the severity of mitral regurgitation. Mitral valve quantification (MVQ) software of Qlab 8.1 was used for image post-processing of RT3D-TEE. The coaptation parameters was measured, included length of anterior combination(LCA3dlf), length of posterior combination(LCP3dlf), area of anterior combination(A3DTANT) and area of posterior combination(A3DTPOST) at end-systole. Then, these coaptation parameters of mitral valve were compared statistically. Logistic regression assessing was applied for analyzing the results. Results Coaptation line of anterior and posterior leaflets was almost same in normal subjects. With increasing of mitral regurgitation, a tendency to prolong in LCA3dlf and LCP3dlf were observed in IMR (P<0.05). Compared to that in mild and moderate IMR groups, besides A3DTANT and A3DTPOST, LCA3dlf and LCP3dlf were also increased significantly in severe IMR group (P<0.05). LCP3dlf was an independent correlation factor of IMR by Logistic regression analysis. The sensitivity was 73.3% and the specificity was 94.7% when LCP3dlf ≥32 mm was regarded as cut-off point, and the area under the ROC curve was 0.949 (0.900~0.999). Conclusions Abnormal coaptation of anterior and posterior leaflets of mitral valve might be one of main cause of IMR. Involution structure of mitral valve before surgery is helpful for surgeon to select an optical surgical procedure and evaluate effects of treatment in patients with IMR. Key words: Echocardiography, real-time three-dimensional; Echocardiography, transesophageal; Mitral valve insufficiency; Myocardial ischemia

Echocardiographic quantification of mitral valvular response to myocardial revascularization

Mild and/or moderate ischemic mitral regurgitation (IMR) may resolve after isolated coronary artery bypass grafting (CABG). It has been shown that the loss of saddle shape of the mitral valve is associated with IMR and is determined by an increase in the nonplanarity angle (NPA). The aim of this prospective, observational study was to test the hypothesis that NPA might decrease immediately after CABG alone in patients with mild to moderate IMR. This prospective, observational study was conducted in an academic, tertiary care hospital. Twenty patients underwent 2D and 3D transoesophageal echocardiography (TEE) and mitral valve assessment before and immediately after the CABG. NPA, circularity index, and other geometric variables were obtained. They were compared using paired t test. The SPSS (Version 15.0, Chicago, IL, USA) was used for statistical analysis. P <0.05 was considered significant. The NPA was similar in the pre- and post-bypass periods (148° ± 15°, 148° ± 19°, P = 0.88). Circularity index (0.93 ± 0.13, 0.97 ± 0.11, P = 0.41) also was similar. There was no change in the mitral valve NPA with revascularization alone in patients with mild or moderate IMR. Mitral valve does not change its planarity (NPA) with revascularization alone in patients with IMR.