Mechanism of functional mitral regurgitation during acute myocardial ischemia

Henry Ford Heart and Vascular Institute, Detroit, Michigan.

The mechanism and temporal manifestation of functional mitral regurgitation after acute myocardial ischemia were examined in eight dogs. Regional ischemia was produced by selective microembolization of the left circumflex coronary artery. Mitral regurgitation and regional left ventricular wall motion abnormalities were evaluated with use of Doppler color flow mapping and two-dimensional echocardiography, respectively. Measurements were made at baseline (before embolization) and were repeated at 30 min and 3 weeks after embolization. Mitral regurgitation developed in all dogs 30 min after embolization and completely subsided 3 weeks later. There was no evidence of mitral valve prolapse, mitral anulus dilation or left ventricular segmental dyskinesia at any time during the study. Regional wall motion analysis showed only hypokinesia of the left ventricular segment overlying the papillary muscle at 30 min with subsequent normalization of the segment at 3 weeks. Mitral regurgitation was accompanied by an increase of the end-systolic distance between the mitral anulus plane and the point of coaptation of the mitral leaflets. This distance was 0.5 +/- 0.1 cm at baseline, increased to 0.9 +/- 0.1 cm 30 min after the embolization (p less than 0.001) and returned to near baseline (0.6 +/- 0.1 cm) 3 weeks after the embolization. These data indicate that mitral valve prolapse, mitral anulus dilation and regional left ventricular dyskinesia are not necessary conditions for the development of functional mitral regurgitation after acute myocardial ischemia. Instead, hypokinesia of the ventricular segment overlying the papillary muscle and leading to retraction of the mitral leaflets toward the apex appears to be a sufficient condition for incomplete leaflet coaptation.

This article has been cited by other articles:

				W. Y. Szeto, R. C. Gorman, J. H. Gorman III, and M. A. Acker Ischemic Mitral Regurgitation Card. Surg. Adult, January 1, 2008; 3(2008): 785 - 802. [Full Text]

				J. Kwan, M. A. Gillinov, J. D. Thomas, and T. Shiota Geometric predictor of significant mitral regurgitation in patients with severe ischemic cardiomyopathy, undergoing Dor procedure: A real-time 3D echocardiographic study Eur J Echocardiogr, June 1, 2007; 8(3): 195 - 203. [Abstract] [Full Text] [PDF]

				E. Messas, A. Bel, M. C. Morichetti, C. Carrion, M. D. Handschumacher, S. Peyrard, J. T. Vilquin, M. Desnos, P. Bruneval, A. Carpentier, et al. Autologous Myoblast Transplantation for Chronic Ischemic Mitral Regurgitation J. Am. Coll. Cardiol., May 16, 2006; 47(10): 2086 - 2093. [Abstract] [Full Text] [PDF]

				T. Uemura, Y. Otsuji, K. Nakashiki, S. Yoshifuku, Y. Maki, B. Yu, N. Mizukami, E. Kuwahara, S. Hamasaki, S. Biro, et al. Papillary Muscle Dysfunction Attenuates Ischemic Mitral Regurgitation in Patients With Localized Basal Inferior Left Ventricular Remodeling: Insights From Tissue Doppler Strain Imaging J. Am. Coll. Cardiol., July 5, 2005; 46(1): 113 - 119. [Abstract] [Full Text] [PDF]

				H. K. Eltzschig, S. K. Shernan, and P. Rosenberger Ischemic Mitral Regurgitation during Temporary Coronary-Artery Ligation N. Engl. J. Med., June 3, 2004; 350(23): 2424 - 2425. [Full Text] [PDF]

				G. G. Pellizzon, C. L. Grines, D. A. Cox, T. Stuckey, J. E. Tcheng, E. Garcia, G. Guagliumi, M. Turco, A. J. Lansky, J. J. Griffin, et al. Importance of mitral regurgitation inpatients undergoing percutaneous coronaryintervention for acute myocardial infarction: The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Trial J. Am. Coll. Cardiol., April 21, 2004; 43(8): 1368 - 1374. [Abstract] [Full Text] [PDF]

				P. Lancellotti, F. Lebrun, and L. A. Pierard Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1921 - 1928. [Abstract] [Full Text] [PDF]

				R. A. Levine and J. Hung Ischemic mitral regurgitation, the dynamic lesion: clues to the cure J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1929 - 1932. [Full Text] [PDF]

				E. Messas, B. Pouzet, B. Touchot, J. L. Guerrero, G. J. Vlahakes, M. Desnos, P. Menasche, A. Hagege, and R. A. Levine Efficacy of Chordal Cutting to Relieve Chronic Persistent Ischemic Mitral Regurgitation Circulation, September 9, 2003; 108(90101): II-111 - 115. [Abstract] [Full Text] [PDF]

				J. Kwan, T. Shiota, D. A. Agler, Z. B. Popovic, J. X. Qin, M. A. Gillinov, W. J. Stewart, D. M. Cosgrove, P. M. McCarthy, and J. D. Thomas Geometric Differences of the Mitral Apparatus Between Ischemic and Dilated Cardiomyopathy With Significant Mitral Regurgitation: Real-Time Three-Dimensional Echocardiography Study Circulation, March 4, 2003; 107(8): 1135 - 1140. [Abstract] [Full Text] [PDF]

				S. N. Konstadt The Interaction Between the Cardiac Anesthesiologist and the CardiacSurgeon in the Management of Acute Heart Failure: The Role of Transesophageal Echocardiography Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2003; 7(1): 45 - 48. [PDF]

				T. Kumanohoso, Y. Otsuji, S. Yoshifuku, K. Matsukida, C. Koriyama, A. Kisanuki, S. Minagoe, R. A. Levine, and C. Tei Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: Quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 135 - 143. [Abstract] [Full Text] [PDF]

				R. C. Gorman, J. H. Gorman III, and L. H. Edmunds Jr. Ischemic Mitral Regurgitation Card. Surg. Adult, January 1, 2003; 2(2003): 751 - 769. [Full Text]

				D. T. Lai, T. A. Timek, F. A. Tibayan, G. R. Green, G. T. Daughters, D. Liang, N. B. Ingels Jr, and D. C. Miller The effects of mitral annuloplasty rings on mitral valve complex 3-D geometry during acute left ventricular ischemia Eur. J. Cardiothorac. Surg., November 1, 2002; 22(5): 808 - 816. [Abstract] [Full Text] [PDF]

				T. A. Timek, D. T. Lai, F. Tibayan, D. Liang, F. Rodriguez, G. T. Daughters, P. Dagum, N. B. Ingels Jr, and C. Miller Annular Versus Subvalvular Approaches to Acute Ischemic Mitral Regurgitation Circulation, September 24, 2002; 106(12_suppl_1): I-27 - I-32. [Abstract] [Full Text] [PDF]

				G Breithardt, H Kuhn, D Hammel, H.-H Scheld, L Seipel, and D. Bocker Cardiac resynchronization therapy into the next decade: from the past to morbidity/mortality trials Eur. Heart J. Suppl., April 1, 2002; 4(suppl_D): D102 - D110. [Abstract] [PDF]

				E. Messas, J. L. Guerrero, M. D. Handschumacher, C.-M. Chow, S. Sullivan, E. Schwammenthal, and R. A. Levine Paradoxic Decrease in Ischemic Mitral Regurgitation With Papillary Muscle Dysfunction: Insights From Three-Dimensional and Contrast Echocardiography With Strain Rate Measurement Circulation, October 16, 2001; 104(16): 1952 - 1957. [Abstract] [Full Text] [PDF]

				E. Messas, J. L. Guerrero, M. D. Handschumacher, C. Conrad, C.-M. Chow, S. Sullivan, A. P. Yoganathan, and R. A. Levine Chordal Cutting: A New Therapeutic Approach for Ischemic Mitral Regurgitation Circulation, October 16, 2001; 104(16): 1958 - 1963. [Abstract] [Full Text] [PDF]

				F. Grigioni, M. Enriquez-Sarano, K. J. Zehr, K. R. Bailey, and A. J. Tajik Ischemic Mitral Regurgitation : Long-Term Outcome and Prognostic Implications With Quantitative Doppler Assessment Circulation, April 3, 2001; 103(13): 1759 - 1764. [Abstract] [Full Text] [PDF]

				Y. Otsuji, M. D. Handschumacher, N. Liel-Cohen, H. Tanabe, L. Jiang, E. Schwammenthal, J. L. Guerrero, L. A. Nicholls, G. J. Vlahakes, and R. A. Levine Mechanism of ischemic mitral regurgitation with segmental left ventricular dysfunction: three-dimensional echocardiographic studies in models of acute and chronic progressive regurgitation J. Am. Coll. Cardiol., February 1, 2001; 37(2): 641 - 648. [Abstract] [Full Text] [PDF]

				D. T. M. Lai, T. A. Timek, P. Dagum, G. R. Green, J. R. Glasson, G. T. Daughters, D. Liang, N. B. Ingels Jr, and D. C. Miller The effects of ring annuloplasty on mitral leaflet geometry during acute left ventricular ischemia J. Thorac. Cardiovasc. Surg., November 1, 2000; 120(5): 966 - 975. [Abstract] [Full Text] [PDF]

				S. F. Yiu, M. Enriquez-Sarano, C. Tribouilloy, J. B. Seward, and A. J. Tajik Determinants of the Degree of Functional Mitral Regurgitation in Patients With Systolic Left Ventricular Dysfunction : A Quantitative Clinical Study Circulation, September 19, 2000; 102(12): 1400 - 1406. [Abstract] [Full Text] [PDF]

				N. Liel-Cohen, J. L. Guerrero, Y. Otsuji, M. D. Handschumacher, L. G. Rudski, P. R. Hunziker, H. Tanabe, M. Scherrer-Crosbie, S. Sullivan, and R. A. Levine Design of a New Surgical Approach for Ventricular Remodeling to Relieve Ischemic Mitral Regurgitation : Insights From 3-Dimensional Echocardiography Circulation, June 13, 2000; 101(23): 2756 - 2763. [Abstract] [Full Text] [PDF]

				R. J. Gibbons, K. Chatterjee, J. Daley, J. S. Douglas, S. D. Fihn, J. M. Gardin, M. A. Grunwald, D. Levy, B. W. Lytle, R. A. O'Rourke, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina) J. Am. Coll. Cardiol., June 1, 1999; 33(7): 2092 - 2197. [Full Text] [PDF]

				S. L. Nielsen, H. Nygaard, A. A. Fontaine, J. M. Hasenkam, S. He, N. T. Andersen, and A. P. Yoganathan Chordal force distribution determines systolic mitral leaflet configuration and severity of functional mitral regurgitation J. Am. Coll. Cardiol., March 1, 1999; 33(3): 843 - 853. [Abstract] [Full Text] [PDF]

				J. Hung, Y. Otsuji, M. D. Handschumacher, E. Schwammenthal, and R. A. Levine Mechanism of dynamic regurgitant orifice area variation in functional mitral regurgitation: Physiologic insights from the proximal flow convergence technique J. Am. Coll. Cardiol., February 1, 1999; 33(2): 538 - 545. [Abstract] [Full Text] [PDF]

				Y. Otsuji, D. Gilon, L. Jiang, S. He, M. Leavitt, M. J. Roy, M. J. Birmingham, and R. A. Levine Restricted diastolic opening of the mitral leaflets in patients with left ventricular dysfunction: evidence for increased valve tethering J. Am. Coll. Cardiol., August 1, 1998; 32(2): 398 - 404. [Abstract] [Full Text] [PDF]

				S. He, A. A. Fontaine, E. Schwammenthal, A. P. Yoganathan, and R. A. Levine Integrated Mechanism for Functional Mitral Regurgitation : Leaflet Restriction Versus Coapting Force: In Vitro Studies Circulation, September 16, 1997; 96(6): 1826 - 1834. [Abstract] [Full Text]

				Y. Otsuji, M. D. Handschumacher, E. Schwammenthal, L. Jiang, J.-K. Song, J. L. Guerrero, G. J. Vlahakes, and R. A. Levine Insights From Three-Dimensional Echocardiography Into the Mechanism of Functional Mitral Regurgitation : Direct In Vivo Demonstration of Altered Leaflet Tethering Geometry Circulation, September 16, 1997; 96(6): 1999 - 2008. [Abstract] [Full Text]

				M. D. Cheitlin, J. S. Alpert, W. F. Armstrong, G. P. Aurigemma, G. A. Beller, F. Z. Bierman, T. W. Davidson, J. L. Davis, P. S. Douglas, L. D. Gillam, et al. ACC/AHA Guidelines for the Clinical Application of Echocardiography : A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography) Developed in Collaboration With the American Society of Echocardiography Circulation, March 18, 1997; 95(6): 1686 - 1744. [Full Text]

				H. Shimoyama, H. N. Sabbah, S. Borzak, M. Tanimura, S. Shevlyagin, G. Scicli, and S. Goldstein Short-term Hemodynamic Effects of Endothelin Receptor Blockade in Dogs With Chronic Heart Failure Circulation, August 15, 1996; 94(4): 779 - 784. [Abstract] [Full Text]