What is the recommended treatment for a patient with multiple jet mitral regurgitation and ischemic heart disease who is a candidate for Coronary Artery Bypass Grafting (CABG)?

Management of Multiple Jet Mitral Regurgitation with Ischemic Heart Disease Undergoing CABG

For patients with multiple jet mitral regurgitation and ischemic heart disease who are candidates for CABG, surgery is indicated with concomitant mitral valve repair or replacement when the mitral regurgitation is severe and the left ventricular ejection fraction is >30%. 1

Assessment and Classification

• Echocardiography is essential to establish the diagnosis of ischemic mitral regurgitation, assess its severity, and evaluate valve anatomy and function 1
• In secondary (ischemic) mitral regurgitation, lower thresholds define severe MR compared to primary MR (EROA ≥20 mm² and regurgitant volume ≥30 mL) 1
• The severity of mitral regurgitation should be reassessed after optimized medical treatment before making surgical decisions 1
• Secondary MR is a dynamic condition; echocardiographic quantification during exercise may help determine the need for combined surgery 1

Surgical Management Algorithm

Severe Ischemic Mitral Regurgitation:

• LVEF >30%: Mitral valve surgery is recommended concomitantly with CABG (Class I, Level C) 1
• LVEF ≤30%: Mitral valve surgery may be considered with CABG (Class IIb, Level C) 1

Moderate Ischemic Mitral Regurgitation:

• With viable posteroinferior wall: CABG without mitral valve surgery may be considered (Class IIb, Level B) 1
• Without viable posteroinferior wall: Mitral valve surgery should be considered with CABG (Class IIb, Level C) 1
• The addition of mitral valve repair provides more durable correction of MR but has not been shown to significantly improve survival at 2 years 2

Choice of Mitral Valve Procedure

• Mitral valve repair is the preferred method for most patients with ischemic MR 1

  • Typically performed with small undersized rigid annuloplasty ring (Class IIa, Level B) 1
  • Associated with lower residual MR grade compared to CABG alone 3

• Mitral valve replacement should be considered in patients with:

  • Unfavorable morphological characteristics 1
  • High risk of MR recurrence 1
  • Chordal-sparing techniques should be used during replacement to preserve ventricular function 1

Important Considerations and Caveats

• Outcomes of mitral valve repair depend significantly on surgeon experience and center volume 1

• The type of annuloplasty (suture vs. ring) has not been shown to influence outcomes, but surgeon experience is a significant factor 4

• Risk factors for poor outcomes after repair include:

  • Preoperative severe MR 4
  • Poor left ventricular ejection fraction 4
  • Limited surgeon experience 4

• Combined CABG, left ventricular restoration, and mitral valve repair may be effective for patients with left ventricular aneurysm and ischemic MR 5

• Patients undergoing combined CABG and mitral valve surgery may experience:

  • Higher rates of neurologic events and supraventricular arrhythmias compared to CABG alone 2
  • No significant improvement in left ventricular reverse remodeling at 2 years compared to CABG alone 2

Follow-up Management

• Optimal medical therapy for heart failure should be administered to all patients with secondary MR (ACE inhibitors/ARBs, beta-blockers, MRAs) 1
• Cardiac resynchronization therapy should be performed if indicated for heart failure (Class I, Level A) 1
• Regular echocardiographic follow-up is essential to monitor for recurrent MR, which occurs in approximately 20% of patients after repair 4