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Ischaemic mitral regurgitation is a distinctive valve disease in that, unlike with organic valvulopathies, abnormalities of the left ventricle are not the consequence but the cause of the valve disease. Ischaemic mitral regurgitation is more a pathology of the muscle than the valve and the characteristics of the underlying coronary disease are important determinants of clinical presentation and prognosis.
Important advances in the understanding of pathophysiology, evaluation, and prognosis have occurred during recent years and confirmed that ischaemic mitral regurgitation has many specific features which differentiates it from organic regurgitations. The evaluation of the results of the different therapeutic methods has also improved, even if their relevance in clinical practice is limited by the heterogeneity of the disease and the number of confounding factors.
PATHOPHYSIOLOGY
Except in cases of papillary muscle rupture, ischaemic mitral regurgitation is a functional mitral regurgitation characterised by structurally normal leaflets and subvalvar apparatus. Mitral regurgitation is the consequence of a restriction in the motion of the leaflets—that is, a type 3 according to the Carpentier‘s classification. Leaflet tethering displaces the coaptation zone from the mitral annulus towards the apex of the left ventricle, thereby determining an incomplete closure of the mitral valve in systole, also called systolic tenting because of the echocardiographic aspect (fig 1).1
Normal coaptation (left) and leaflet tethering by annular dilatation and papillary muscle displacement (right). AO, aorta; Inf PM, inferior papillary muscle; LA, left atrium; LV, left ventricle; MR, mitral regurgitation. Reproduced from Levine et al,1 with permission of the publisher.
The modifications of the geometry and motion of the subvalvular apparatus as a consequence of ischaemic cardiopathy are the main determinants of ischaemic mitral regurgitation. Local remodelling of the left ventricle displaces papillary muscles and leads to a traction on the mitral leaflets. Incomplete leaflet closure may also …
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