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Ann Thorac Surg 2005;80:170-178
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Ischemic Mitral Regurgitation: Impact of the Left Ventricle and Mitral Valve in Patients with Left Ventricular Systolic Dysfunction

Monvadi B. Srichai, MDa,b, Richard A. Grimm, DOb, Arthur E. Stillman, MD, PhDa, A. Marc Gillinov, MDc, L. Leonardo Rodriguez, MDb, Michael L. Lieber, MSd, Abigail Lara, MDb, Joan A. Weaver, RT, (R)MRa, Patrick M. McCarthy, MDc, Richard D. White, MDa,b,c,*

a Department of Radiology, Section of Cardiovascular Imaging, Cleveland Clinic Foundation, Cleveland, Ohio
b Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
c Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
d Department of Biostatistics and Epidemiology, Cleveland Clinic Foundation, Cleveland, Ohio

Accepted for publication January 10, 2005.

* Address reprint requests to Dr White, Center for Integrated Non-Invasive Cardiovascular Imaging, Desk HB6, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH44195 (Email: whiter{at}ccisd1.ccf.org).

BACKGROUND: Mitral regurgitation (MR) is a common complication of ischemic heart disease, and its presence portends adverse outcomes. As the exact mechanisms of ischemic MR are not well defined, we characterized left ventricular global geometry, regional function, and regional myocardial scarring, in addition to mitral valve apparatus geometry, using magnetic resonance imaging (MRI) of ischemic heart disease patients with left ventricular dysfunction and varying degrees of ischemic MR.

METHODS: Sixty patients with varying degrees of MR (none, mild, moderate, and severe) determined by echocardiography and referred for MRI assessment of ischemic heart disease were included. Left ventricular geometric, functional, and scar measurements in addition to mitral valve geometric measurements were evaluated.

RESULTS: Clinical characteristics found to be significant predictors of degree of MR included severity of coronary artery disease (p < 0.05), completeness of myocardial perfusion (p < 0.005), and average systolic blood pressure (p < 0.05). Mitral systolic tenting area (p < 0.0001) in a statistical model with scarring of the anterior-lateral region (p < 0.05) proved to be the most powerful predictor of MR severity (r2 = 0.31). Mitral annular dilatation in the anterior-posterior direction (p < 0.0001) and diminished LV systolic function (p < 0.005) were important determinants of mitral systolic tenting area (r2 = 0.57).

CONCLUSIONS: Mitral tenting in combination with regional left ventricular myocardial scarring are important mechanisms to the development of ischemic MR. Surgical annuloplasty addresses mitral tenting, but has little impact on the effect of regional scarring. Moderate-to-severe ischemic MR develops in patients with regional scarring of the anterior-lateral and inferior-posterior regions, and new surgical developments should take this into account.




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