Ischemic mitral regurgitation (MR) is a frequent complication of myocardial infarction (MI), doubling the risk of developing heart failure and mortality. Its primary mechanism is leaflet tethering due to disturbed left ventricular geometry from myocardial scarring and remodeling of the heart as a result of the MI.

The incidence in the U. S. is impressive. Approximately 1 million people are diagnosed with a MI annually, with 50% developing ischemic mitral regurgitation. In patients with viable myocardium, coronary bypass surgery may reverse the left ventricular remodeling and improve the MR.

Unfortunately, 50% of patients with moderate or severe ischemic MR will have persistence or worsening of their mitral regurgitation after revascularization alone, requiring mitral valve surgery.

In this heart failure population, studies have shown that performing a mitral valve repair, using a restrictive annuloplasty ring, regrettably results in a 50% chance of recurrent, severe MR, at long-term follow-up —which leads to even poorer long-term survival. Therefore, a chordal-sparing valve replacement will likely provide a more durable result —and better outcomes— over mitral valve repair, in these critically I’ll patients.

Based on the current literature, and my personal experience, my choice of intervention for severe ischemic mitral regurgitation is to place a bovine mitral prosthetic valve, with concomitant clip occlusion of the left atrial appendage, due to the high risk of postoperative atrial fibrillation.

With the advent of valve-in-valve trans-catheter mitral valve replacement (TMVR), the patient will have a percutaneous option should the prosthetic valve leaflets deteriorate in the future. Indeed, sometime in the future, TMVR may become the standard of choice for the primary mitral valve operation.