Improving Repair Durability in Severe Ischemic Mitral Regurgitation: Revisiting Patient Selection and Adjunctive Repair Techniques.

Ischemic mitral regurgitation (IMR) is a complex heterogeneous complication following myocardial infarction, characterized by left ventricular (LV) remodeling and subsequent valvular distortion. The primary mechanisms include papillary muscle displacement, mitral leaflet tethering, and impaired coaptation following annular dilatation. IMR is associated with poor prognosis and an increased incidence of heart failure. We reviewed studies on the surgical management of IMR published over the past 2 decades. While mitral valve repair has been favored for its advantages of low perioperative mortality and LV function preservation, high rates of mitral regurgitation recurrence limit its long-term durability. Regarding repair strategy, apart from restrictive mitral annuloplasty, the adjunctive techniques of papillary muscle relocation, papillary muscle approximation, and leaflet augmentation have been proposed. These approaches aim to address LV remodeling and improve leaflet coaptation by mitigating subvalvular tethering. Moreover, the application of true-size annuloplasty and "functional repair" strategies in IMR patients with enlarged LV emphasizes the need to tailor interventions to patients' LV dimensions and dynamic changes. Accumulating clinical evidence highlights the importance of meticulous patient selection and functional mitral valve repair, which remains a promising approach contingent on enhanced understanding of IMR's pathophysiology and its interplay with LV remodeling. The current review summarizes our patient selection criteria and indications for surgical repair (including the use of adjunctive techniques of subvalvular intervention) or mitral valve replacement.