Abstract

Objective: To investigate mitral regurgitation occurring early in the course of acute myocardial infarction with respect to its incidence, the impact of infarct size and location, the accuracy of clinical detection, the contribution of global and regional left ventricular performance, and its influence on prognosis.

Design: Prospective observational study derived from patients entering Phase I of the Thrombolysis in Myocardial Infarction (TIMI) trial.

Setting: Multicenter trial involving 13 universityaffiliated medical centers.

Patients: A total of 206 patients studied within 7 hours of symptom onset during their first myocardial infarction.

Measurements: Contrast left ventriculography was used to document mitral regurgitation.

Results: Mitral regurgitation was present in 27 patients (13%). Although the presence of regurgitation correlated with the site of infarction (20 of 27 had anterior infarctions) and the number of akinetic chords, it was not statistically related to the peak creatine kinase value or to left ventricular chamber size or filling pressure. A murmur of mitral regurgitation was heard in only 2 patients (1 incorrectly). The presence of early mitral regurgitation predicted cardiovascular mortality at 1 year by univariate (relative risk, 12.2; 95% Cl, 3.5 to 42; P < 0.0001) and multivariate (relative risk, 7.5; Cl, 2.0 to 28.6; P = 0.0008) analyses.

Conclusions: Mitral regurgitation in early myocardial infarction is generally clinically "silent," is more common in anterior infarction, is associated with regional dysfunction but not early ventricular dilation or peak enzyme release, and is an important predictor of cardiovascular mortality.

References

  • 1. Phillips JBurch G, and De Pasquale N. The syndrome of papillary muscle dysfunction. Ann Intern Med. 1963;59:508-20. LinkGoogle Scholar
  • 2. Heikkilä J. Mitral incompetence complicating acute myocardial infarction. Br Heart J. 1967;29:162-9. CrossrefMedlineGoogle Scholar
  • 3. Burch GDePasquale N, and Phillips J. Clinical manifestations of papillary muscle dysfunction. Arch Intern Med. 1963;112:158-63. CrossrefMedlineGoogle Scholar
  • 4. . The thrombolysis in myocardial infarction (TIMI) trial. N Engl J Med. 1985;312:932-6. CrossrefMedlineGoogle Scholar
  • 5. Williams DBorer JBraunwald EChesebro JCohen L, and Dalen J. Intravenous recombinant tissue-type plasminogen activator in patients with acute myocardial infarction: a report from the NHLBI thrombolysis in myocardial infarction trial. Circulation. 1986;73:338-46. CrossrefMedlineGoogle Scholar
  • 6. Sheehan FBraunwald ECanner PDodge HGore J, and Van Natta P. The effect of intravenous thrombolytic therapy on left ventricular function: a report on tissue-type plasminogen activator and streptokinase from the thrombolysis in myocardial infarction (TIMI Phase I) trial. Circulation. 1987;75:817-29. CrossrefMedlineGoogle Scholar
  • 7. Sandler H and Dodge H. The use of single plane angiocardiograms for the calculation of left ventricular volume in man. Am Heart J. 1968;75:325-34. CrossrefMedlineGoogle Scholar
  • 8. Sheehan FBolson EDodge HMathey DSchofer J, and Woo H. Advantages and applications of the centerline method for characterizing regional ventricular function. Circulation. 1986;74:293-305. CrossrefMedlineGoogle Scholar
  • 9. Berger PRuocco NRyan TDiver DSharaf B, and Feit F. Incidence and significance of mitral regurgitation following first myocardial infarction treated with rt-PA: results from TIMI II [Abstract]. J Am Coll Cardiol. 1991;17:247A. CrossrefGoogle Scholar
  • 10. Gahl KSutton RPearson MCaspari PLairet A, and McDonald L. Mitral regurgitation in coronary heart disease. Br Heart J. 1977;39:13-8. CrossrefMedlineGoogle Scholar
  • 11. Zeldis SHamby R, and Aintablian A. The clinical and hemodynamic significance of mitral regurgitation in coronary artery disease. Cathet Cardiovasc Diagn. 1980;6:225-32. CrossrefMedlineGoogle Scholar
  • 12. Maisel AGilpin EKlein LLe Winter MHenning H, and Collins D. The murmur of papillary muscle dysfunction in acute myocardial infarction: clinical features and prognostic implications. Am Heart J. 1986;112:705-11. CrossrefMedlineGoogle Scholar
  • 13. Barzilai BDavis VStone P, and Jaffe A. Prognostic significance of mitral regurgitation in acute myocardial infarction. Am J Cardiol. 1990;65:1169-75. CrossrefMedlineGoogle Scholar
  • 14. Barzilai BGessler CPerez JSchaab C, and Jaffe A. Significance of Doppler-detected mitral regurgitation in acute myocardial infarction. Am J Cardiol 1988;61:220-3. CrossrefMedlineGoogle Scholar
  • 15. Braunwald E. Valvular heart disease In: Braunwald E; ed. Heart disease: a Textbook of Cardiovascular Medicine. Philadelphia: WB Saunders Co.; 1988:1042. Google Scholar
  • 16. Forrester JDiamond GFreedman SAllen HParmley WMatloff J, and Swan H. Silent mitral insufficiency in acute myocardial infarction. Circulation. 1971;44:877-83. CrossrefMedlineGoogle Scholar
  • 17. Blumlein SBouchard ASchiller NDae MByrd BPorts T, and Botvinick E. Quantitation of mitral regurgitation by doppler echocardiography. Circulation. 1986;74:306-14. CrossrefMedlineGoogle Scholar
  • 18. Izumi SMiyatake KBeppu SShintaro BPark Y, and Nagata S. Mechanism of mitral regurgitation in patients with myocardial infarction: a study using real-time two-dimensional Doppler flow imaging and echocardiography. Circulation. 1987;76:777-85. CrossrefMedlineGoogle Scholar
  • 19. Perloff J and Roberts W. The mitral apparatus: functional anatomy of mitral regurgitation. Circulation. 1972;46:227-39. CrossrefMedlineGoogle Scholar
  • 20. Wei JHutchins G, and Bulkley B. Papillary muscle rupture in fatal acute myocardial infarction. A potentially treatable form of cardiogenic shock. Ann Intern Med. 1979;90:149-53. LinkGoogle Scholar
  • 21. Roberts W and Cohen L. Left ventricular papillary muscles: description of the normal and a survey of conditions causing them to be abnormal. Circulation. 1972;46:138-54. CrossrefMedlineGoogle Scholar
  • 22. Cheng T. Some new observations on the syndrome of papillary muscle dysfunction. Am J Med. 1969;47:924-45. CrossrefMedlineGoogle Scholar
  • 23. Brand EBerge K, and Brown A. Papillary muscles in myocardial infarction. Circulation. 1967;36:75-91. Google Scholar
  • 24. Burch GDePasquale N, and Phillips J. The syndrome of papillary muscle dysfunction. Am Heart J. 1968;75:399-415. CrossrefMedlineGoogle Scholar
  • 25. Tei CSakamaki TShah PMeerbaum SKondo SShimoura K, and Corday E. Mitral valve prolapse in short-term experimental coronary occlusion: a possible mechanism of ischemic mitral regurgitation. Circulation. 1983;68:183-9. CrossrefMedlineGoogle Scholar
  • 26. Hirakawa SSasayama STomoike HCrozathier BFranklin DMcKown D, and Ross J. In situ measurement of papillary muscle dynamics in the dog left ventricle. Am J Physiol. 1977;233:H384-91. MedlineGoogle Scholar
  • 27. Miller GCohn KKerth WSelzer A, and Gerbode F. Experimental papillary muscle infarction. J Thorac Cardiovasc Surg. 1968; 56:611-6. CrossrefMedlineGoogle Scholar
  • 28. Tsakiris ARastelli GAmorim DDTitus J, and Wood E. Effect of experimental papillary muscle damage on mitral valve closure in intact anesthetized dogs. Mayo Clin Proc. 1970;45:275-85. MedlineGoogle Scholar
  • 29. Mittal ALangston MCohn KSelzer A, and Kerth W. Combined papillary muscle and left ventricular wall dysfunction as a cause of mitral regurgitation. Circulation. 1971;44:174-80. CrossrefMedlineGoogle Scholar
  • 30. Godley RWann LRogers EFeigenbaum H, and Weyman A. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation. 1981;63:565-71. CrossrefMedlineGoogle Scholar
  • 31. Kinney E and Frangi M. Value of two-dimensional echocardiographic detection of incomplete mitral leaflet closure. Am Heart J. 1985; 109:87-90. CrossrefMedlineGoogle Scholar
  • 32. Ogawa SHubbard FMardelli T, and Dreifus L. Cross-sectional echocardiographic spectrum of papillary muscle dysfunction. Am Heart J. 1979;97:312-21. CrossrefMedlineGoogle Scholar
  • 33. Nishimura RSchaff HShub CGersh BEdwards W, and Tajik A. Papillary muscle rupture complicating acute myocardial infarction: analysis of 17 patients. Am J Cardiol. 1983;51:373-7. CrossrefMedlineGoogle Scholar
  • 34. Barbour D and Roberts W. Rupture of a left ventricular papillary muscle during acute myocardial infarction: analysis of 22 necropsy patients. J Am Coll Cardiol. 1986;8:558-65. CrossrefMedlineGoogle Scholar
  • 35. Gross L. The Blood Supply to the Heart in its Anatomical and Clinical Aspects. New York: Paul B. Hoeber, Inc., Medical Book Division of Harper & Row; 1921. Google Scholar
  • 36. Spalteholz W. Die arteriendie Herzwand, Leipzig. S Hirzel; 1924. Google Scholar
  • 37. . Risk stratification and survival after myocardial infarction. N Engl J Med. 1983;309:331-6. CrossrefMedlineGoogle Scholar
  • 38. Mukharji JRude RPoole WGustafson IThomas L, and Strauss H. Risk factors for sudden death after acute myocardial infarction: two-year follow-up. Am J Cardiol. 1984;54:31-6. CrossrefMedlineGoogle Scholar
  • 39. Ahnve SGilpin EHenning HCurtis GCollins D, and Ross J. Limitations and advantages of the ejection fraction for defining high risk after acute myocardial infarction. Am J Cardiol. 1986;58:872-8. CrossrefMedlineGoogle Scholar
  • 40. Radford MJohnson RBuckley MDaggett WLeinbach R, and Gold H. Survival following mitral valve replacement for mitral regurgitation due to coronary artery disease. Circulation. 1979;60:I-39-47. CrossrefMedlineGoogle Scholar
  • 41. Pinson CCobanoglu AMetzdorff MGrunkemeier GKay P, and Starr A. Late surgical results for ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 1984;88:663-72. CrossrefMedlineGoogle Scholar
  • 42. Najafi MJavid HHunter JGoldin MSerry C, and Dye W. Mitral insufficiency secondary to coronary heart disease. Ann Thorac Surg. 1975;20:529-37. CrossrefMedlineGoogle Scholar
  • 43. Hickey MSmith LMuhlbaier LHarrell FReves J, and Hinohara T. Current prognosis of ischemic mitral regurgitation: implications for future management. Circulation. 1988;78(Suppl II):I-51-9. Google Scholar
  • 44. Replogle R and Campbell C. Surgery for mitral regurgitation associated with ischemic heart disease. Circulation. 1989;79(Suppl I):I-122-5. Google Scholar

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