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CLINICAL RESEARCH: VALVULAR HEART DISEASE

Prevention of ischemic mitral regurgitation does not influence the outcome of remodeling after posterolateral myocardial infarction

T. Sloane Guy, IV, MD^*, Sina L. Moainie, MD^*, Joseph H. Gorman, III, MD^*, Benjamin M. Jackson, MD^*, Theodore Plappert, CVT, Yoshiharu Enomoto, MD^*, Martin G. St. John-Sutton, MBBS, FACC, L. Henry Edmunds, Jr, MD^* and Robert C. Gorman, MD^*,*

^* Harrison Department of Surgical Research, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

Manuscript received April 4, 2003; revised manuscript received July 17, 2003, accepted July 21, 2003.

^* Reprint requests and correspondence: Dr. Robert C. Gorman, Department of Surgery, 6 Silverstein, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, Pennsylvania 19104, USA.
gormanr{at}uphs.upenn.edu

OBJECTIVES: This study was designed to test the hypothesis that ischemic mitral regurgitation (IMR) results from, but does not influence, the progression of left ventricular (LV) remodeling after posterolateral infarction.

BACKGROUND: Surgical correction of chronic IMR is being increasingly recommended.

METHODS: Three groups of sheep had coronary snares placed around the second and third obtuse marginal coronary arteries. Occlusion of these vessels in the control group resulted in progressive IMR over eight weeks. In a second group, Merseline mesh was fitted to cover the exposed LV before infarction. In a third group, a ring annuloplasty was placed before infarction to prevent IMR. Remodeling and degree of IMR were assessed with echocardiography at baseline and at 30 min and two, five, and eight weeks after infarction.

RESULTS: Eight weeks after infarction, mean IMR grade was significantly higher in control animals than mesh and annuloplasty animals. At eight weeks, LV end-systolic volume and end-systolic muscle-to-cavity-area ratio (ESMCAR) were significantly better in mesh-treated sheep than in control sheep; also, at eight weeks, ESMCAR and akinetic segment length were significantly better in mesh-treated sheep than in annuloplasty sheep. Ejection fraction was significantly higher in the mesh than the annuloplasty group. There was no significant difference in any measure of remodeling between the annuloplasty and control groups.

CONCLUSIONS: Prophylactic ventricular restraint reduces infarct expansion, attenuates adverse remodeling, and reduces IMR severity. Prevention of IMR by prophylactic ring annuloplasty does not influence remodeling. Ischemic mitral regurgitation is a consequence, not a cause, of postinfarction remodeling; infarct expansion is the more important therapeutic target.

Abbreviations and Acronyms   ANOVA = analysis of variance   CHF = congestive heart failure   EF = ejection fraction   ESMCAR = end-systolic muscle-to-cavity-area ratio   IMR = ischemic mitral regurgitation   IV = intravenous   LV = left ventricle   LVEDV = left ventricular end-diastolic volume   LVESV = left ventricular end-systolic volume   LVP = left ventricular pressure   MI = myocardial infarction   WMA = wall motion abnormality

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