Circulation. 2005;112:745-758
doi: 10.1161/CIRCULATIONAHA.104.486720
doi: 10.1161/CIRCULATIONAHA.104.486720
(Circulation. 2005;112:745-758.)
© 2005 American Heart Association, Inc.
Contemporary Reviews in Cardiovascular Medicine |
Ischemic Mitral Regurgitation on the Threshold of a Solution
From Paradoxes to Unifying Concepts
From the Cardiac Ultrasound Laboratory (R.A.L.), Cardiology Division, Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, Mass, and the Cardiac Rehabilitation Institute (E.S.), Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Correspondence to Robert A. Levine, MD, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, YOCC 5068, Boston, MA 02114. E-mail rlevine@partners.org
Key Words: echocardiography • mitral valve • myocardial infarction • regurgitation • surgery
An extract of the first 250 words of the full text is provided, because this article has no abstract. |
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Introduction |
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"More than once in history the discovery of paradox has been the occasion for major reconstruction at the foundations of thought."— W.V. Quine, The Ways
One thing is certain: Ischemic mitral regurgitation (MR) conveys adverse prognosis, doubling mortality after myocardial infarction (MI), in chronic heart failure, and after surgical or catheter revascularization.1–9 It is common and increases mortality even when mild,3–5 with a graded relationship between severity and reduced survival (Figure 1A).5
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In many other respects, however, ischemic MR has been a study in controversy and paradox. Its diagnosis is notoriously elusive, both by auscultation and intraoperatively. It may paradoxically decrease as driving pressure increases. Still commonly referred to as "papillary muscle dysfunction," it cannot generally be produced by direct papillary muscle damage and may actually decrease with papillary muscle ischemia. Although leaflet motion is typically restricted, it may also be excessive, or both. Treatment benefit is hotly debated and will be difficult to resolve so long as existing therapies are incompletely effective in permanently abolishing MR. New therapeutic opportunities are perplexing in their diversity. By exploring such areas of confusion, we
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