Türkçe
Français
Italiano
Ischemic mitral regurgitation is a condition in which the structurally completely healthy mitral valve leaflets cannot close fully and allow blood to leak backward as a result of inadequate blood supply to the heart muscle or enlargement and reshaping of the heart after a heart attack. In this condition, the main problem is not in the tissue of the valve itself, but in the loss of shape of the heart chamber that supports the valve. When the structure supporting the valve stretches and enlarges, a gap inevitably remains no matter how intact the flexible leaflets acting as doors are, and the normal direction of blood flow is disrupted. This leakage, which strains the pumping power of the heart, gradually disturbs the natural balance of the circulatory system and prevents oxygenated blood needed by the organs from being distributed efficiently throughout the body.
| What Is Ischemic Mitral Regurgitation? | Ischemic mitral regurgitation is a valve disease that develops when the mitral valve cannot close completely because of damage to the heart muscle and papillary muscles supporting the valve after coronary artery disease or a heart attack (myocardial infarction), even though the structure of the mitral valve is usually normal. |
| Mechanism of Development | Damage to the heart muscle or a change in the shape of the left ventricle (ventricular remodeling) causes displacement of the papillary muscles. As a result, the mitral valve leaflets cannot close completely, and blood leaks backward from the left ventricle into the left atrium. |
| Most Common Cause | Myocardial infarction due to coronary artery disease is the most common cause. It may be seen more frequently especially after inferior wall infarctions. |
| Risk Factors | Coronary artery disease, previous heart attack, hypertension, diabetes, smoking, high cholesterol, obesity, advanced age, and chronic kidney disease are among the risk factors. |
| Symptoms | Shortness of breath, decreased exercise capacity, easy fatigue, palpitations, nighttime shortness of breath, swelling in the legs, and symptoms of heart failure may occur. |
| Acute Ischemic Mitral Regurgitation | Severe mitral regurgitation that develops suddenly may occur in serious complications such as partial or complete rupture of a papillary muscle. This condition may lead to severe pulmonary edema and circulatory impairment and may be life-threatening. |
| Chronic Ischemic Mitral Regurgitation | It develops as a result of enlargement and reshaping of the left ventricle over time after a heart attack. Symptoms may progress slowly. |
| Physical Examination Findings | A systolic heart murmur, sounds associated with fluid accumulation in the lungs, tachycardia, and signs of heart failure may be detected. |
| Diagnostic Methods | Transthoracic echocardiography is the primary diagnostic method. When necessary, transesophageal echocardiography, electrocardiography (ECG), coronary angiography, cardiac MRI, stress imaging methods, and laboratory tests may be performed. |
| Importance of Echocardiography | It is the fundamental method for evaluating in detail the severity of mitral regurgitation, left ventricular functions, the condition of the papillary muscles, and the movements of the valve leaflets. |
| Severity of the Disease | It is classified as mild, moderate, and severe mitral regurgitation. The treatment plan is determined according to symptoms, left ventricular function, and the severity of regurgitation. |
| Treatment Goals | The goals are to reduce mitral regurgitation, control heart failure symptoms, improve quality of life, slow the progression of the disease, and prolong survival. |
| Medication Treatment | Medications used in the treatment of heart failure, diuretics, and other cardiovascular medications may be used in suitable patients. Treatment for coronary artery disease is also applied. |
| Coronary Artery Treatment | In suitable patients, revascularization of the coronary arteries with stenting or coronary artery bypass grafting (CABG) may positively affect both heart muscle functions and the severity of mitral regurgitation. |
| Surgical Treatment | Mitral valve repair or valve replacement may be performed in selected patients. When necessary, it may be carried out together with coronary bypass surgery. |
| Catheter-Based Treatment | Transcatheter mitral valve repair methods may be considered in suitable patients with high surgical risk. |
| Complications | Heart failure, atrial fibrillation, pulmonary hypertension, recurrent hospitalizations, rhythm disorders, and an increased risk of death may occur. |
| Follow-Up | Regular cardiology checkups, echocardiography at specified intervals, and effective treatment of coronary artery disease are important. |
| Lifestyle Recommendations | Quitting smoking, controlling blood pressure and diabetes, regulating cholesterol levels, following a heart-healthy diet, engaging in regular physical activity, and complying with the physician’s recommendations are advised. |
| Prognosis | The course of the disease depends on the severity of mitral regurgitation, left ventricular function, the extent of coronary artery disease, and the treatment applied. Early diagnosis and appropriate treatment may improve long-term outcomes. |
| When Should Emergency Care Be Sought? | Emergency medical evaluation is required when sudden severe shortness of breath, chest pain, fainting, severe palpitations, pink frothy sputum, altered consciousness, or rapidly worsening symptoms of heart failure develop. |
What Is Ischemic Mitral Regurgitation?
When healthy, the heart muscle usually has a shape resembling an ellipse and a strong contractile form. This elliptical structure makes it easier for the heart to pump blood forcefully throughout the body with each beat and for the valves inside to come together. However, tissues damaged after a heart attack alter the anatomical balance of the heart, paving the way for this elliptical structure to gradually become more spherical and ball-like. When the left ventricle, which is the main pump of the heart, enlarges and loses its shape in this way, the internal cords and muscles that hold the mitral valve in place begin to be pulled downward and sideways.
This pulling movement makes it difficult for the flexible leaflets of the valve to move freely and close. The leaflets are subjected to a restriction as though they were suspended backward by invisible strings from within. At the same time, the outer ring on which the valve sits also enlarges in response to the growth of the heart. These leaflets, which are both pulled from below and have a stretched supporting frame, can no longer meet in the middle when the heart contracts. This defect along the line of closure creates a wide gap through which blood can leak backward instead of flowing in the correct direction. In medical practice, this mechanism is considered a natural consequence of the heart’s remodeling process rather than a primary structural valve disease.
What Changes Occur in Our Body in Ischemic Mitral Regurgitation?
Blood leaking backward from the left ventricle first fills the left atrium, which is responsible for receiving and holding oxygenated blood from the lungs. This thin-walled chamber, normally accustomed only to blood flow from the lungs, is placed under considerable strain by the additional blood arriving from below in the opposite direction and under high pressure. The left atrium begins to stretch and enlarge over time to relieve this burden. However, this enlargement may further impair the valve structure and increase the amount of leakage. In the medical literature, this condition is described as the disease entering a self-perpetuating cycle.
The increasing backward pressure does not remain limited to the left atrium and progresses toward the lungs, which are the original source of the blood. Increased fluid pressure in the small vessels of the lungs may cause fluid to leak into the tissues and make the lungs feel heavy like a sponge. When this back-pressure effect continues for a long time, the right side of the heart also begins to tire because it has difficulty working against this high pressure. The entire circulatory dynamics of the body may be affected by this closure defect in the valve.
The main parts of the body affected by this hemodynamic burden over time are as follows:
- Left atrium
- Pulmonary vessels
- Right heart chambers
- Leg veins
- Abdominal cavity
What Are the Main Complaints Seen in Patients with Ischemic Mitral Regurgitation?
The complaints that arise during the course of the disease generally vary according to the severity of the valve leakage and how well the heart can adapt to this condition. In the early stages, many people may not feel any discomfort because the body can tolerate this additional burden. However, as the amount of leakage increases and fluid accumulation in the lungs begins to appear, findings that restrict daily life become evident. Patients generally begin to feel unusual fatigue during activities they used to perform very comfortably, such as climbing stairs or walking up a slight incline.
In advanced cases, a feeling of pressure in the chest or inability to breathe may occur when lying down in bed at night. This is caused by fluid in the legs shifting toward the lungs when the effect of gravity is removed and may cause patients to need to sleep with multiple pillows. As circulation slows, fluid accumulation may be observed in the ankles, which are the lowest points of the body.
Common symptoms that reduce quality of daily life during this process are as follows:
- Shortness of breath
- Easy fatigue
- Feeling of palpitations
- Nighttime cough
- Ankle swelling
- General weakness
Why Do the Symptoms of Ischemic Mitral Regurgitation Increase During Exertion?
One of the most complex aspects of this condition is its highly variable and dynamic nature. Sometimes, evaluations performed at rest may show only very mild leakage through the valve, and it may be thought that there is a discrepancy between the patient’s complaints and the test results. However, when the person goes for a walk, carries shopping bags, or encounters a stressful situation, shortness of breath may suddenly become severe.
The main reason for this is that the muscles need more oxygen while the body is active, and the heart tries to contract faster and more forcefully to meet this demand. The increase in heart rate and blood pressure during exertion also suddenly raises the pressure inside the heart. The valve gap, which may remain at a tolerable level at rest, allows much more blood to leak backward because of this increased internal pressure. This pressure wave, which rises toward the lungs within seconds, causes the person to suddenly become breathless. Therefore, stress echocardiography examinations performed by exercising the heart play a very important role in determining the timing of treatment and revealing the true condition.
What Are the Main Medication Groups Used in the Treatment of Ischemic Mitral Regurgitation?
When this type of acquired insufficiency in the heart valve is detected, the first approach is to reduce the burden on the heart rather than directly performing a mechanical intervention on the valve. Current clinical guidelines recommend maximizing medical treatment because the main problem is fatigue and enlargement of the heart muscle. This treatment plan is carefully arranged to create an environment in which the heart can work more comfortably and to slow the enlargement process. The regular use of these medications under physician supervision and at appropriate tolerated doses also lays the groundwork for the success of possible interventional procedures that may be performed at later stages. If there is a mismatch in the electrical conduction system of the heart, special pacemakers that allow different regions of the heart to work simultaneously may also be added to these medications.
Medical treatments frequently used to improve the working conditions of the heart are as follows:
- Diuretics
- Blood pressure regulators
- Rhythm regulators
- Blood thinners
- Pacemakers
Can Valve Leakage Due to Ischemic Mitral Regurgitation Be Repaired Without Open Surgery?
When complaints that make daily life difficult continue despite medication use and pacemaker support, direct mechanical intervention on the valve may be considered. In previous years, the solution to such problems usually involved conventional surgical operations performed by opening the chest. However, traditional surgeries may carry high risks for this patient group, who have already had a heart attack, have weakened heart muscle, and are generally of advanced age. The process of stopping the heart and connecting it to a machine may lead to a difficult recovery period in patients with fragile physical conditions.
Today, thanks to advancing technology, it has become possible to repair the valve without opening the chest or stopping the heart. These innovative techniques, known in the medical world as percutaneous transcatheter methods, make it possible to reach directly into the heart through thin tubes inserted from a vessel in the groin. The heart continues to beat normally during the procedure, thereby protecting the heart muscle. For patients who may struggle to tolerate the trauma caused by conventional surgery, these methods offer valuable alternatives that shorten hospital stays and accelerate the return to daily life.
How Is the Clipping Method Applied in the Treatment of Ischemic Mitral Regurgitation?
Among non-surgical treatment options, the method with the most experience and scientific evaluation today is known as clipping or fastening the valve. The main aim of this method is to bring together the valve leaflets that have moved apart and no longer close because the heart has enlarged, thereby narrowing the gap between them. The procedure is generally performed while the patient is under general anesthesia and under the guidance of a special ultrasound device placed in the esophagus. This ultrasound allows physicians to see the inside of the heart in three dimensions and in real time, making millimetric movements possible.
After entering through the main vein in the groin, flexible delivery tubes are advanced to the right atrium of the heart. A small passage is created through the thin membrane separating the right and left sides of the heart, and the left side containing the affected valve is reached. A special alloy clip located at the tip of this thin tube, smaller than a coin, is aligned directly over the valve leaflets. After identifying the point where blood leaks backward the most, the free edges of the valve leaflets are grasped between the arms of the clip and the device is carefully closed. In this way, instead of one large opening that allows leakage, two smaller openings are created through which blood can pass easily but cannot flow backward. After the procedure, patients are generally expected to be discharged within a few days and return to their normal lives.
What Kind of Solution Does Indirect Annuloplasty Offer for Ischemic Mitral Regurgitation?
When the clipping procedure is not anatomically suitable or a different mechanical correction is needed, methods aimed at narrowing the frame on which the heart valve sits from the outside come into use. In this technique, known as indirect annuloplasty, the mobile leaflets of the valve are not touched directly. Instead, a special device is placed inside a large vein called the coronary sinus, which runs immediately around the heart valve and collects the heart’s own deoxygenated blood.
This mechanical device, again advanced through the groin and placed inside this vessel, gradually creates tension in the area where it is positioned. Just as a loose garment is tightened from the outside with a belt, this device helps constrict and narrow the enlarged mitral valve ring from the outside inward. When the frame supporting the valve becomes narrower, the valve leaflets that have moved apart gain the opportunity to come closer together again. This technique, performed without stopping the heart, may help reduce backward blood leakage by supporting the anatomical form of the heart.
What Are the Main Differences Between the Treatments for Valve Stenosis and Ischemic Mitral Regurgitation?
All minimally invasive procedures performed on heart valves are sometimes confused with one another in the general population. However, the inability of a valve to open because of calcification and the inability of a valve to close because of enlargement of the heart involve completely opposite mechanisms, and the devices used work according to entirely opposite principles. In valve stenosis, the problem is that blood cannot move forward, whereas in regurgitation, the problem is that blood returns backward uncontrollably. Therefore, the approaches to these two conditions are very different.
The general features of the methods used in stenosis are as follows:
- Balloon dilation
- Separation of adhesions
- Stretching of calcifications
The aims of the procedures performed in ischemic mitral regurgitation are as follows:
- Bringing the leaflets closer together
- Narrowing the frame
- Limiting the leakage
Which Patients Are Suitable Candidates for Interventional Ischemic Mitral Regurgitation Procedures?
For these innovative procedures to provide maximum benefit to patients, it is vitally important that they be performed at the right time and in individuals with suitable anatomy. Scientific studies have shown that not every patient with valve regurgitation benefits equally from these procedures. The patient group most likely to benefit consists of individuals whose hearts are not excessively enlarged despite having very severe valve leakage. This condition, in which the leakage is much greater in proportion to the size of the heart, is called “disproportionate regurgitation.” The hearts of patients in this group still have the potential to recover, and when the valve leakage is corrected, the burden on the heart may be dramatically reduced.
The main characteristics sought in candidates who are considered likely to benefit from the procedure are as follows:
- Persistent complaints
- Preserved contraction strength
- A heart that is not excessively enlarged
- Severe valve leakage
In Which Situations Is Interventional Treatment for Ischemic Mitral Regurgitation Not Preferred?
As with every medical intervention, there are certain situations in which interventional valve repair procedures may be risky or technically impossible to perform. To prioritize patient safety, specific risk factors are investigated during detailed examinations before the procedure. For example, in people with extensive calcification of the valve leaflets, it may become difficult for the device to grasp the tissue, or the procedure may further narrow the existing structure and lead to different problems. Likewise, if an infection or blood clot is detected inside the heart, these procedures may be postponed or cancelled because performing them could create a basis for serious complications.
The main factors that may prevent the procedure from being performed are as follows:
- Extensive valve calcification
- Active tissue infection
- Intracardiac clot
- Bleeding tendency
- Unsuitable valve size
Frequently Asked Questions
Prof. Dr. Kadriye Orta Kılıçkesmez is one of the leading figures in the field of Turkish cardiology. She was born on January 24, 1974, in Tekirdağ. After completing her undergraduate education at Istanbul University Cerrahpaşa Faculty of Medicine, she chose cardiology as her specialty and received her specialist training at the Cardiology Institute of the same university. In 2015, she was appointed by the university to establish the Şişli Etfal cardiology clinic and Angio laboratory. Becoming a professor in 2017, Kadriye Kılıçkesmez established the cardiology clinic and Angio laboratory of Prof. Dr. Cemil Taşçı Hospital in 2020 and ensured that the clinic became a training clinic.
