Treatment Strategy for Chronic Ischemic Mitral Regurgitation

Chronic ischemic mitral regurgitation (MR) is a functional valvular disorder that occurs secondary to left ventricular remodeling due to old myocardial infarction or chronic myocardial ischemia. The presence of ischemic MR promotes further left ventricular remodeling and results in adverse outcomes. The goals of ischemic MR treatment are durable control of MR, left ventricular reverse remodeling, and improvement of the survival. However, surgical repair of the mitral valve alone may fail to achieve these goals. Furthermore, the mid-term mortality rate after endovascular repair remains high, although its survival benefit over medication was proven in a recent randomized trial. Therefore, to achieve these goals, treatment should target not only the mitral valve but also the left ventricle. In addition to maximally tolerated medical treatment and complete coronary revascularization, surgical procedures targeting the left ventricular should be added to mitral procedure to minimize the risk of adverse outcomes. Chordal preservation in the replacement of the mitral valve and subvalvular procedure is known to achieve left ventricular remodeling. Left ventriculoplasty can ameliorate adverse effects related to myocardial scarring. Despite the lack of evidence, such procedures have the potential to improve outcomes and may contribute to establishing an optimal treatment strategy. In this paper, the relationship between the pathological conditions of ischemic MR, predictors of adverse outcomes, and the effect of each treatment option was summarized by reviewing the literature.