Ischemia-Mediated Dysfunction in Subpapillary Myocardium as a Marker of Functional Mitral Regurgitation.

Journal Article (Journal Article)

OBJECTIVES: The goal of this study was to test whether ischemia-mediated contractile dysfunction underlying the mitral valve affects functional mitral regurgitation (FMR) and the prognostic impact of FMR. BACKGROUND: FMR results from left ventricular (LV) remodeling, which can stem from myocardial tissue alterations. Stress cardiac magnetic resonance can assess ischemia and infarction in the left ventricle and papillary muscles; relative impact on FMR is uncertain. METHODS: Vasodilator stress cardiac magnetic resonance was performed in patients with known or suspected coronary artery disease at 7 sites. Images were centrally analyzed for MR etiology/severity, mitral apparatus remodeling, and papillary ischemia. RESULTS: A total of 8,631 patients (mean age 60.0 ± 14.1 years; 55% male) were studied. FMR was present in 27%, among whom 16% (n = 372) had advanced (moderate or severe) FMR. Patients with ischemia localized to subpapillary regions were more likely to have advanced FMR (p = 0.003); those with ischemia localized to other areas were not (p = 0.17). Ischemic/dysfunctional subpapillary myocardium (odds ratio: 1.24/10% subpapillary myocardium; confidence interval: 1.17 to 1.31; p < 0.001) was associated with advanced FMR controlling for infarction. Among a subgroup with (n = 372) and without (n = 744) advanced FMR matched (1:2) on infarct size/distribution, patients with advanced FMR had increased adverse mitral apparatus remodeling, paralleled by greater ischemic/dysfunctional subpapillary myocardium (p < 0.001). Although posteromedial papillary ischemia was more common with advanced FMR (p = 0.006), subpapillary ischemia with dysfunction remained associated (p < 0.001), adjusting for posteromedial papillary ischemia (p = 0.074). During follow-up (median 5.1 years), 1,473 deaths occurred in the overall cohort; advanced FMR conferred increased mortality risk (hazard ratio: 1.52; 95% confidence interval: 1.25 to 1.86; p < 0.001) controlling for left ventricular ejection fraction, infarction, and ischemia. CONCLUSIONS: Ischemic and dysfunctional subpapillary myocardium provides a substrate for FMR, which predicts mortality independent of key mechanistic substrates.

Full Text

Duke Authors

Cited Authors

  • Kochav, JD; Kim, J; Judd, R; Kim, HW; Klem, I; Heitner, J; Shah, D; Shenoy, C; Farzaneh-Far, A; Polsani, V; Kalil, R; Villar-Calle, P; Nambiar, L; Sultana, R; Parker, M; Cargile, P; Khalique, OK; Leon, MB; Karmpaliotis, D; Ratcliffe, M; Levine, R; Zoghbi, WA; Devereux, RB; Moskowitz, CS; Kim, R; Weinsaft, JW

Published Date

  • April 2021

Published In

Volume / Issue

  • 14 / 4

Start / End Page

  • 826 - 839

PubMed ID

  • 33744130

Pubmed Central ID

  • PMC8086776

Electronic International Standard Serial Number (EISSN)

  • 1876-7591

Digital Object Identifier (DOI)

  • 10.1016/j.jcmg.2021.01.007


  • eng

Conference Location

  • United States