“ More than once in history the discovery of paradox has been the occasion for major reconstruction at the foundations of thought .” — W.V. Quine, The Ways
One thing is certain: Ischemic mitral regurgitation (MR) conveys adverse prognosis, doubling mortality after myocardial infarction (MI), in chronic heart failure, and after surgical or catheter revascularization.1–9 It is common and increases mortality even when mild,3–5 with a graded relationship between severity and reduced survival (Figure 1A).5
Figure 1. A, Decreased survival after MI with increasing MR. Effective regurgitant orifice (ERO) area of 20 mm2 demarcates mild from moderate. Reprinted with permission from Grigioni et al.5 Copyright 2001, American Heart Association, Inc. B, Decreased survival after cardiogenic shock with increasing MR for comparable LV ejection fraction (LVEF). Reprinted with permission from Picard et al.8 Copyright 2003, American Heart Association, Inc.
In many other respects, however, ischemic MR has been a study in controversy and paradox. Its diagnosis is notoriously elusive, both by auscultation and intraoperatively. It may paradoxically decrease as driving pressure increases. Still commonly referred to as “papillary muscle dysfunction,” it cannot generally be produced by direct papillary muscle damage and may actually decrease with papillary muscle ischemia. Although leaflet motion is typically restricted, it may also be excessive, or both. Treatment benefit is hotly debated and will be difficult to resolve so long as existing therapies are incompletely effective in permanently abolishing MR. New therapeutic opportunities are perplexing in their diversity. By exploring such areas of confusion, we aim to clarify fundamental principles and achieve more effective solutions.
Ischemic MR is convenient shorthand for MR caused by changes in ventricular structure and function related ultimately to ischemia; it is predominantly postinfarction MR. Active ischemia can contribute, for example, creating intermittent “flash” pulmonary edema, …