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

Assessment and Classification

The European Society of Cardiology recommends that echocardiography is essential to establish the diagnosis of ischemic mitral regurgitation, assess its severity, and evaluate valve anatomy and function 2, 3
In secondary (ischemic) mitral regurgitation, lower thresholds define severe MR compared to primary MR (EROA ≥20 mm² and regurgitant volume ≥30 mL) 2, 4
The severity of mitral regurgitation should be reassessed after optimized medical treatment before making surgical decisions 3, 5
Secondary MR is a dynamic condition; echocardiographic quantification during exercise may help determine the need for combined surgery 2, 4

For patients with severe ischemic mitral regurgitation and left ventricular ejection fraction (LVEF) >30%, the European Society of Cardiology recommends mitral valve surgery concomitantly with CABG (Class I, Level C) 2, 3, 4
For patients with severe ischemic mitral regurgitation and LVEF ≤30%, the European Society of Cardiology suggests that mitral valve surgery may be considered with CABG (Class IIb, Level C) 1, 6
For patients with moderate ischemic mitral regurgitation and viable posteroinferior wall, the European Society of Cardiology recommends that CABG without mitral valve surgery may be considered (Class IIb, Level B) 1, 6

The European Society of Cardiology recommends mitral valve repair as the preferred method for most patients with ischemic MR 2, 3
Mitral valve repair is typically performed with small undersized rigid annuloplasty ring (Class IIa, Level B) 1, 6
The European Society of Cardiology suggests that mitral valve replacement should be considered in patients with unfavorable morphological characteristics 2, 3 or high risk of MR recurrence 1
Chordal-sparing techniques should be used during replacement to preserve ventricular function 1

The European Society of Cardiology recommends that optimal medical therapy for heart failure should be administered to all patients with secondary MR (ACE inhibitors/ARBs, beta-blockers, MRAs) 7, 5
Cardiac resynchronization therapy should be performed if indicated for heart failure (Class I, Level A) 7