Ischemic Ischemic Mitral Regurgitation Mitral Regurgitation Jean- - PowerPoint PPT Presentation

Ischemic Ischemic Mitral Regurgitation Mitral Regurgitation Jean- -Louis J. Vanoverschelde, MD, Louis J. Vanoverschelde, MD, PhD PhD Jean Université é catholique de catholique de Louvain Louvain Universit Brussels, , Belgium Belgium Brussels

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Definition Definition Ischemic mitral regurgitation is mitral regurgitation due to Ischemic mitral regurgitation is mitral regurgitation due to complications of coronary artery disease, in particular, myocardial ial complications of coronary artery disease, in particular, myocard infarction, and not the fortuitous association of coronary artery y infarction, and not the fortuitous association of coronary arter disease with intrinsic valve disease such as rheumatic disease, or or disease with intrinsic valve disease such as rheumatic disease, mitral valve prolapse. mitral valve prolapse.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation • In the acute phase of myocardial infarction, ischemic mitral In the acute phase of myocardial infarction, ischemic mitral • regurgitaion is frequent and appears to carry an adverse prognosis. is. regurgitaion is frequent and appears to carry an adverse prognos • In the chronic post In the chronic post- -myocardial infarction phase, angiographic myocardial infarction phase, angiographic • mitral regurgitaion is frequent (> 19% grade II MR) and is mitral regurgitaion is frequent (> 19% grade II MR) and is predictive of survival, even if mild to moderate in severity. predictive of survival, even if mild to moderate in severity. • For diagnosis purposes, murmur is of limited value. Objective • For diagnosis purposes, murmur is of limited value. Objective methods are therefore required. methods are therefore required.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Prognostic value of MR in ischemic heart disease Prognostic value of MR in ischemic heart disease • 303 patients (mean age 70 303 patients (mean age 70 ± ± 10 yrs) with a first Q 10 yrs) with a first Q- -wave wave • MI older than 16 days before baseline assessment. MI older than 16 days before baseline assessment. • Exclusion criteria : Exclusion criteria : • • MI ≤ ≤ 16 days 16 days • MI • Previous surgery • Previous surgery • Papillary muscle rupture • Papillary muscle rupture • MR of organic origin • MR of organic origin • • Significant AR Significant AR Grigioni et al., Circulation Grigioni et al., Circulation . 2001;103:1759. . 2001;103:1759.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Prognostic value of MR in ischemic heart disease Prognostic value of MR in ischemic heart disease IMR no IMR p value IMR no IMR p value (n=194) (n=109) (n=194) (n=109) Age, y 71± ±11 11 70± ±9 9 0.20 Age, y 71 70 0.20 Men 135 (70%) 86 (79%) 0.08 Men 135 (70%) 86 (79%) 0.08 NYHA III– –IV IV 92 (47%) 38 (35%) 0.034 NYHA III 92 (47%) 38 (35%) 0.034 A. Fib. 30 (15%) 5 (5%) 0.004 A. Fib. 30 (15%) 5 (5%) 0.004 SBP 132± ±26 26 141± ±26 26 0.004 SBP 132 141 0.004 Anterior MI 40 (21%) 44 (40%) 0.001 Anterior MI 40 (21%) 44 (40%) 0.001 EF, % 33± ±14 14 34± ±11 11 0.14 EF, % 33 34 0.14 LVS, mm/m² LVS, mm/m ² 28± 28 ±6 6 26± 26 ±6 6 0.003 0.003 LVD, mm/m² ² 33± ±5 5 31± ±5 5 0.001 LVD, mm/m 33 31 0.001 Grigioni et al., Circulation Grigioni et al., Circulation . 2001;103:1759. . 2001;103:1759.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Prognostic value value of of MR in MR in ischemic ischemic heart heart disease disease Prognostic 100 100 MI without without MR MR MI 80 80 Survival (%) (%) 61± 61 ±6% 6% 60 60 Survival MI with with MR MR MI 40 40 38 38± ±5% 5% 20 20 P<0.001 P<0.001 0 0 0 12 24 36 48 60 0 12 24 36 48 60 Time (months Time ( months) ) Grigioni et al., Circulation Grigioni et al., Circulation . 2001;103:1759. . 2001;103:1759.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Multivariate predictors of overall survival Multivariate predictors of overall survival RR 95% CI p value RR 95% CI p value Age 1.03 1.01- -1.05 1.05 < 0.001 Age 1.03 1.01 < 0.001 EF 0.98 0.97- -1.00 1.00 0.030 EF 0.98 0.97 0.030 NYHA III- -IV IV 1.88 1.27- -2.79 2.79 0.002 NYHA III 1.88 1.27 0.002 Diabetes 1.48 0.99- -2.20 2.20 0.054 Diabetes 1.48 0.99 0.054 A. Fib. 1.62 1.00- -2.62 2.62 0.049 A. Fib. 1.62 1.00 0.049 1/Creatinine 0.44 0.21- -0.94 0.94 0.034 1/Creatinine 0.44 0.21 0.034 R. Vol. < 30 mL 1.64 0.98- -2.75 2.75 0.059 R. Vol. < 30 mL 1.64 0.98 0.059 R. Vol. ≥ ≥ 30 mL 30 mL 2.05 1.30- -3.23 3.23 0.002 R. Vol. 2.05 1.30 0.002 Grigioni et al., Circulation Grigioni et al., Circulation . 2001;103:1759. . 2001;103:1759.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Prognostic value value of of MR in MR in ischemic ischemic heart heart disease disease Prognostic ERO > 20 mm 2 2 ERO > 20 mm and/or /or and RV > 30 mL RV > 30 mL adjusted RR: 2.01 RR: 2.01 - - 2.38 2.38 adjusted Grigioni et al., Circulation Grigioni et al., Circulation . 2001;103:1759. . 2001;103:1759.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Prognostic value value of of MR in MR in ischemic ischemic heart heart disease disease Prognostic 100 100 80 80 Survival (%) (%) 61± 61 ±6% 6% 60 60 Survival 44 44± ±9% 9% RVol RVol 40 40 36 36± ±7% 7% 0 0 1- 1 -29 29 20 20 P < 0.0001 P < 0.0001 > 30 > 30 0 0 0 12 24 36 48 60 0 12 24 36 48 60 Time (months Time ( months) ) Grigioni et al., Circulation Grigioni et al., Circulation . 2001;103:1759. . 2001;103:1759.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Prognostic value value of of MR in MR in ischemic ischemic heart heart disease disease Prognostic 100 100 80 80 Survival (%) (%) 61± 61 ±6% 6% 60 60 Survival 47± ±8% 8% 47 ERO ERO 40 40 0 0 29± ±9% 9% 29 1- 1 -19 19 20 20 P < 0.0001 P < 0.0001 > 20 > 20 0 0 0 12 24 36 48 60 0 12 24 36 48 60 Time (months Time ( months) ) Grigioni et al., Circulation Grigioni et al., Circulation . 2001;103:1759. . 2001;103:1759.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Impact of iMR on the development of heart failure on the development of heart failure Impact of iMR 100 100 P<0.001 P<0.001 Incidence of CHF (%) Incidence of CHF (%) 80 80 60 60 53± ±7% 7% 53 40 MI with with MR MR 40 MI 20 20 18 18± ±5% 5% MI without without MR MR MI 0 0 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Time (years) Time (years) Grigioni et al., J Am Coll Cardiol Grigioni et al., J Am Coll Cardiol . 2005;45:260. . 2005;45:260.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Impact of iMR on the development of heart failure on the development of heart failure Impact of iMR 100 100 P<0.001 P<0.001 ERO ERO Incidence of CHF (%) Incidence of CHF (%) 0 0 80 80 1 1- -19 19 68± ±12% 12% 68 > 20 > 20 60 60 46± ±9% 9% 46 40 40 20 20 18± 18 ±5% 5% 0 0 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Time (years) Time (years) Grigioni et al., J Am Coll Cardiol Grigioni et al., J Am Coll Cardiol . 2005;45:260. . 2005;45:260.

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Ischemic mitral regurgitation: Type I dysfunction regurgitation: Type I dysfunction Ischemic mitral Type I I Type annular dilatation dilatation annular

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Ischemic mitral regurgitation: Type II dysfunction regurgitation: Type II dysfunction Ischemic mitral Type II Type II Papillary muscle Papillary muscle rupture rupture

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Ischemic mitral regurgitation: Type II dysfunction regurgitation: Type II dysfunction Ischemic mitral Type II Type II Papillary muscle Papillary muscle elongation elongation

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Ischemic mitral regurgitation: Type III dysfunction regurgitation: Type III dysfunction Ischemic mitral Type IIIb Type IIIb Leaflet restriction restriction Leaflet

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Ischemic mitral mitral regurgitation: Decreased closing forces regurgitation: Decreased closing forces Ischemic • Incomplete leaflet Incomplete leaflet and scallop coaptation and scallop coaptation • - Decreased closing forces Decreased closing forces - - Annular dilatation and loss of annular contraction Annular dilatation and loss of annular contraction - - Increased tethering forces Increased tethering forces -

Ischemic Mitral Regurgitation Ischemic Mitral Regurgitation Ischemic mitral mitral regurgitation: Decreased closing forces regurgitation: Decreased closing forces Ischemic • Incomplete leaflet Incomplete leaflet and scallop coaptation and scallop coaptation • - Decreased closing forces Decreased closing forces - - Annular dilatation and loss of annular contraction Annular dilatation and loss of annular contraction - - Increased tethering forces Increased tethering forces -