1. Ischemic Mitral Regurgitation
John M. Connell, MD, MPH, Andrea Worthington, BA, Frederick Y. Chen, MD, PhD, Stanton K. Shernan, MA, FAHA, FASE 
Anesthesiology Clinics 
Volume 31, Issue 2, Pages (June 2013)
DOI: /j.anclin
Copyright © 2013 Elsevier Inc. Terms and Conditions

2. Fig. 1
Carpentier classification scheme for defining MR mechanisms based on leaflet motion abnormalities. Type I: normal leaflet motion (annular dilation; leaflet perforation); type II: increased leaflet motion (prolapse; flail); type III a: leaflet restriction during systole and diastole; type IIIb: leaflet restriction only during systole.
(Modified from Carpentier A, Adams D, Filsoufi F. Carpentier’s reconstructive valve surgery. From valve analysis to valve reconstruction. Philadelphia: Saunders Elsevier; 2010.)
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3. Fig. 2 Multiple causes and complex mechanisms of functional MR.
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4. Fig. 3
Mitral leaflet apical tethering. (A) Transesophageal echocardiography (TEE) midesophageal 4-chamber view showed mild annular dilatation and apical displacement of both leaflets (ie, tethering). (B) High-resolution image showing tethering of both anterior and posterior leaflets. (C) TEE transgastric basal short-axis view showing posterior (yellow arrow) greater than anterior leaflet (white arrow) restriction. LA, left atrium; LV, left ventricle.
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5. Fig. 4
Asymmetric mitral leaflet tethering. Transesophageal midesophageal long-axis view showing anterior mitral leaflet restriction by a strut chord, which produces a hockey-stick deformity (arrow), with posterior leaflet override and an eccentric, posteriorly directed, mitral regurgitant jet.
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6. Fig. 5
Symmetric mitral leaflet tethering. Transesophageal midesophageal 5-chamber view showing bileaflet apical tethering (arrow), which results in a centrally directed, mitral regurgitant jet.
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7. Fig. 6
3D, parametric model of an MV with IMR created using a 3D transesophageal matrix array and software (Q-labs; MVQ; IE33;X7-2t; Philips Healthcare, Andover, MA). (Left) En-face view from left atrial perspective obtained during systole, demonstrating bileaflet tethering and central regurgitant orifice area. (Right). The same MV viewed in the lateral to medial perspective, showing significant tenting height and area associated with apical displacement of both leaflets. A, anterior; AL, anterolateral commissure; Ao, aortic valve; P, posterior; PM, posteromedial commissure.
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8. Fig. 7
Echocardiographic measures predictive of MV repair failure. A tenting height greater than 10 mm has been associated with decreased durability of MV repair for IMR.
(Data from Magne J, Pibarot P, Dagenais F, et al. Preoperative posterior leaflet angle accurately predicts outcome after restrictive valve annuloplasty for ischemic mitral regurgitation. Circulation 2007;115:782–91; and Calafiore AM, Gallina S, DiMauro M, et al. Mitral valve procedure in dilated cardiomyopathy: repair or replacement? Ann Thorac Surg 2001;71:1146–53.)
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9. Fig. 8
3D transesophageal echocardiographic en-face images from the left atrial perspective showing MV repair surgical approaches for patients with IMR. (A) Flat ring annuloplasty (arrow). (B) Saddle-shaped ring annuloplasty (arrow). (C) Edge-to edge repair with central suture between the anterior and posterior leaflets (arrow), producing a double-barrel orifice (asterisks). AV, aortic valve; LA, left atrium.
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10. Fig. 9
3D transesophageal echocardiographic en-face images showing (A) an MV annuloplasty ring dehiscence (arrow) and (B) the corresponding large regurgitant jet (arrow).
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11. Fig. 10
Decision algorithm for chronic IMR. a CSTN trial under way comparing CABG + MV repair (MVP) versus CABG alone for moderate IMR (MR). b ESC and EACTS guidelines class IIa, level C if undergoing CABG and MVP is feasible. c ESC/EACTS guidelines class IIa, level C if target vessels are adequate for CABG. d ESC/EACTS guidelines class I, level C if undergoing CABG. e ESC/EACTS guidelines class IIb, level C, if target vessels are inadequate for CABG, symptoms are refractory to medical therapy, and the patient has low comorbidity.
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12. Anesthesiology Clinics 2013 31, 281-298DOI: (10. 1016/j. anclin. 2013
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