Insights on left ventricular and valvular mechanisms of recurrent ischemic mitral regurgitation after restrictive annuloplasty and coronary artery bypass grafting

Abstract

Preoperative symmetric tethering with anterior mitral leaflet predominance was strongly associated with recurrence of mitral regurgitation. Measures of leaflet tethering resulted in fundamental findings to identify ischemic patients who can really benefit from restrictive annuloplasty. Further larger studies are necessary to confirm our results.

Left Ventricular Reconstruction and Mitral Valve Annuloplasty Combined with Papillary Muscle Relocation for Severe Ischemic Mitral Regurgitation

“…In addition to the exaggeration of posterior leaflet tethering [7], non-improvement in anterior leaflet tethering and continued LV remodeling are reportedly associated with persistence and/or recurrence of MR following MAP [8] [11]. In the present case, continued LV remodeling occurred despite LVR [12].…”

“…In general, symmetrical tethering after an anterior wall MI, which occurred in the present case, is more globally remodeled, spherical, and dysfunctional compared to asymmetrical tethering, which occurs mainly after an inferior wall MI; not only the posterior PM, but also the anterior PM, is displaced and the inter-papillary muscle distance increases. Consequently, the surgical results of MAP for symmetrical tethering are worse compared to those for asymmetrical tethering [8]. LVR for a dilated LV can improve mitral competence by reducing wall stress and decreasing the LV diameter.…”

Surgical Approach to Mitral Regurgitation in Chronic Heart Failure: When Is It an Option?

“…Multiple preoperative echocardiographic factors identify patients at high likelihood of MR recurrence after annuloplasty (Table 2) [43][44][45][46]. They reflect severely dilated and remodeled ventricles with a spherical shape (large systolic and diastolic dimensions, volumes, interpapillary muscle distance, and increased sphericity index) [39••, [43][44][45][46][47][48] that led to severe leaflet tethering reflected on large tenting areas, tenting heights, and leaflet angles [3, 4••, 13, 49•, [50][51][52][53][54]. A central regurgitant jet and complex jets are also a reflection of symmetric tethering and advanced remodeling [23].…”

Mitral Leaflet in Functional Regurgitation

“…The outcome of surgical valve repair in functional MR has been far less successful than for structural MR, and there is increasing understanding of the mechanisms leading to recurrence of regurgitation in both an ischemic 16 and a nonischemic 17 setting.…”