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Chapter 49: Ischemic Mitral Regurgitation

Jonathan Afilalo

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    AMA Citation
    Afilalo J. Afilalo J Afilalo, Jonathan.Ischemic Mitral Regurgitation. In: Eisenberg MJ, Afilalo J, Joza JE, Karra R, Lawler PR. Eisenberg M.J., Afilalo J, Joza J.E., Karra R, Lawler P.R. Eds. Mark J. Eisenberg, et al.eds. Cardiology Board Review and Self-Assessment: A Companion Guide to Hurst's the Heart, 14e New York, NY: McGraw-Hill; . http://accesscardiology.mhmedical.com/content.aspx?bookid=2459&sectionid=193698691. Accessed April 19, 2019.
    MLA Citation
    Afilalo J. Afilalo J Afilalo, Jonathan.. "Ischemic Mitral Regurgitation." Cardiology Board Review and Self-Assessment: A Companion Guide to Hurst's the Heart, 14e Eisenberg MJ, Afilalo J, Joza JE, Karra R, Lawler PR. Eisenberg M.J., Afilalo J, Joza J.E., Karra R, Lawler P.R. Eds. Mark J. Eisenberg, et al. New York, NY: McGraw-Hill, , http://accesscardiology.mhmedical.com/content.aspx?bookid=2459&sectionid=193698691.

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Chapter 49: Ischemic Mitral Regurgitation

A 61-year-old man with a prior history of diet-controlled type 2 diabetes, ischemic heart disease, and COPD was referred for cardiology consultation for a heart murmur. He was a very active man without any cardiovascular symptoms. His physical examination revealed a 2/6 holosystolic murmur loudest at the apex. An echo was obtained showing normal valve leaflets, chords, and annulus; small central MR jet area of 15% LA on Doppler; and mildly dilated LV size with fixed regional wall motion abnormalities. According to the ACC/AHA stages for ischemic MR (IMR), at which of the following stages would this patient be?

A. Stage A

B. Stage B

C. Stage C1

D. Stage C2

E. Stage D

The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 49) The clinical presentation and the echo findings are consistent with stage A, which includes asymptomatic patients at risk of MR, as is the case for this patient (option A). Stages B (option B), C (options C and D), and D (option E) typically include patients with progressive MR, asymptomatic patients with severe disease, and symptomatic subjects with severe MR, respectively. Options B through E are therefore not correct. Stages of secondary MR with associated valve anatomy, valve hemodynamics, cardiac findings, and symptoms are presented in Table 49-1.1

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Table 49-1. Stages of Secondary Mitral Regurgitation with Associated Valve Anatomy, Valve Hemodynamics, Cardiac Findings, and Symptoms
Grade Definition Valve Anatomy Valve Hemodynamics* Associated Cardiac Findings Symptoms
A At risk of MR • Normal valve leaflets, chords, and annulus in a patient with coronary disease or cardiomyopathy

• No MR jet or small central jet area < 20% LA on Doppler

• Small vena contracta < 0.30 cm

• Normal or mildly dilated LV size with fixed (infarction) or inducible (ischemia) regional wall motion abnormalities

• Primary myocardial disease with LV dilation and systolic dysfunction

 • Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
B Progressive MR

• Regional wall motion abnormalities with mild tethering of mitral leaflet

• Annular dilation with mild loss of central coaptation of the mitral leaflets

• ERO < 0.20 cm2†

• Regurgitant volume < 30 mL

• Regurgitant fraction < 50%

• Regional wall motion abnormalities with reduced LV systolic function

• LV dilation and systolic dysfunction due to primary myocardial disease

• Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
C Asymptomatic severe MR

• Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet

• Annular dilation with severe loss of central coaptation of the mitral leaflets

• ERO ...

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