title: Echocardiographic Assessment of Ischaemic Mitral Regurgitation, Mechanism, Severity, Impact on Treatment Strategy and Long Term Outcome.
abstract: BACKGROUND
  The commonest mitral regurgitation etiologies are degenerative (60%), rheumatic post-inflammatory, 12%) and functional (25%). Due to the large number of patients with acute MI, the incidence of ischaemic MR is also high. Ischaemic mitral regurgitation is a complex multifactorial disease that involves left ventricular geometry, the mitral annulus, and the valvular/subvalvular apparatus. Ischaemic mitral regurgitation is an important consequence of LV remodeling after myocardial infarction.
  
  
  OBJECTIVE
  The objective of this study is to determine the role of echocardiography in detecting and assessment of mitral regurgitation mechanism, severity, impact on treatment strategy and long term outcome in patients with myocardial infarction during the follow up period of 5 years. Also one of objectives to determine if the absence or presence of ischaemic MR is associated with increased morbidity and mortality in patients with myocardial infarction.
  
  
  METHODS
  The study covered 138 adult patients. All patients were subjected to echocardiography evaluation after acute myocardial infarction during the period of follow up for 5 years. The patients were examined on an ultrasound machine Philips iE 33 xMatrix, Philips HD 11 XE, and GE Vivid 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated mechanisms and severity of mitral regurgitation which includes the regurgitant volume (RV), effective regurgitant orifice area (EROA), the regurgitant fraction (RF), Jet/LA area, also we measured the of vena contracta width (VC width cm) for assessment of IMR severity, papillary muscles anatomy and displacement, LV systolic function ± dilation, LV regional wall motion abnormality WMA, LV WMI, Left ventricle LV remodeling, impact on treatment strategy and long term mortality.
  
  
  RESULTS
  We analyzed and follow up 138 patients with previous (>16 days) Q-wave myocardial infarction by ECG who underwent TTE and TEE echocardiography for detection and assessment of ischaemic mitral regurgitation (IMR) with baseline age (62 ± 9), ejection fraction (EF 41±12%), the regurgitant volume (RV) were 42±21 mL/beat, and effective regurgitant orifice area (EROA) 20±16 mm(2), the regurgitant fraction (RF) were 48±10%, Jet/LA area 47±12%. Also we measured the of vena contracta width (VC width cm) 0,4±0,6 for assessment of IMR severity. During 5 years follow up, total mortality for patients with moderate/severe IMR-grade II-IV (54.2±1.8%) were higher than for those with mild IMR-grade I (30.4±2.9%) (P<0.05), the total mortality for patients with EROA ≥20 mm(2)(54±1.9%) were higher than for those with EROA <20 mm(2)(27.2±2.7%) (P<0.05), and the total mortality for patients with RVol ≥30 mL (56.8±1.7%) were higher than for those with RVol<30ml (29.4±2.9%) (P<0.05). After assessment of IMR and during follow up period 64 patients (46%) underwent CABG alone or combined CABG with mitral valve repair or replacement. In this study, the procedure of concomitant down-sized ring annuloplasty at the time if CABG surgery has a failure rate around 24% in terms of high late recurrence rate of IMR during the follow period especially after 18-42 months.
  
  
  CONCLUSIONS
  The presence of ischaemic MR is associated with increased morbidity and mortality. Chronic IMR, an independent predictor of mortality with a reported survival of 40-60% at 5 years. Ischaemic mitral regurgitation has important prognosis implications in patients with coronary heart disease. Recognizing the mechanism of valve incompetence is an essential point for the surgical planning and for a good result of the mitral repair. It is important that echocardiographers understand the complex nature of the condition. Despite remarkable progress in reparative surgery, further investigation is still necessary to find the best approach to treat ischaemic mitral regurgitation.
authors.affiliation: Polyclinic "Dr. Nabil", Sarajevo, Bosnia and Herzegovina.
authors.forename: Nabil
authors.initials: N
authors.lastname: Naser
authors.affiliation: Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina.
authors.forename: Alen
authors.initials: A
authors.lastname: Dzubur
authors.affiliation: Department of Cardiology, University Clinical Center Tuzla, Bosnia and Herzegovina.
authors.forename: Zumreta
authors.initials: Z
authors.lastname: Kusljugic
authors.affiliation: Department of Cardiology, University Clinical Center Tuzla, Bosnia and Herzegovina.
authors.forename: Katarina
authors.initials: K
authors.lastname: Kovacevic
authors.affiliation: Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina.
authors.forename: Mehmed
authors.initials: M
authors.lastname: Kulic
authors.affiliation: Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina.
authors.forename: Sekib
authors.initials: S
authors.lastname: Sokolovic
authors.affiliation: BH Heart Center Tuzla, Bosnia and Herzegovina.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Terzic
authors.affiliation: Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina.
authors.forename: Ilirijana
authors.initials: I
authors.lastname: Haxihibeqiri-Karabdic
authors.affiliation: Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina.
authors.forename: Zorica
authors.initials: Z
authors.lastname: Hondo
authors.affiliation: Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina.
authors.forename: Snjezana
authors.initials: S
authors.lastname: Brdzanovic
authors.affiliation: Institute for heart diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina.
authors.forename: Sanja
authors.initials: S
authors.lastname: Miseljic
keywords: Effective regurgitant orifice area (EROA); Ischaemic mitral regurgitation; Mitral annulus dilation; Mitral leaflet tethering; Myocardial infarction; Papillary muscle displacement; Regurgitant fraction (RF); Regurgitant volume (RV); Ventricular remodelling