Solving the puzzle of chronic ischemic mitral regurgitation

Sabet W Hashim, Anthony J Rousou, Arnar Geirsson, Sigurdur Ragnarsson, Sabet W Hashim, Anthony J Rousou, Arnar Geirsson, Sigurdur Ragnarsson

Abstract

Chronic ischemic mitral regurgitation is a prevalent problem among patients following a myocardial infarction. Until recently, the pathophysiology was poorly understood, resulting in surgical strategies with suboptimal results and limited durability. The surgical approach has evolved from revascularization alone to an additional mitral valve procedure, replacement, or repair. When the valve was repaired, isolated annuloplasty was performed. The dilemma that surgeons had when repairing a mitral valve was which type of ring to use and what size. In all series with annuloplasty alone, the results were poor with very high recurrence rates. The primary feature of ischemic mitral regurgitation is a prolapse of the anterior leaflet at A3 +/- A2. This prolapse can be caused by fibrotic elongation of the papillary muscle supporting A3 +/- A2 or tethering of P3 by a ballooning posterior left ventricular wall. Using a technique that corrects this prolapse with Gore-Tex neochords, we have achieved excellent results with effective and durable correction of the ischemic mitral regurgitation.

Figures

Figure 1
Figure 1
Transesophageal echocardiogram showing a complex regurgitant jet in a patient with IMR.
Figure 2
Figure 2
A: Mitral valve after insertion of annuloplasty ring demonstrating a Gore-tex neochord to A3 portion of anterior leaflet in a patient with IMR. B: Mitral valve following completion of ring annuloplasty and neochord to A3 showing even coaptation plane without prolapse.

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