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support the patient because it will decrease afterload, thus limiting the amount of mitral regurgitation. This is similar to the beneficial effect of an intra-aortic balloon pump for post-ventriculoseptal defect in which case the decrease in after-load will limit the amount of left-to-right shunt. Expeditious CABG and MVR should be done since the mortality with expectant management is about 80%. In general, ischemic mitral regurgitation can be classified as acute or chronic. The acute variety is usually the result of papillary muscle rupture (Fig. 5.5) and the chronic variety is usually from ischemic elongation of the chordae or papillary muscles. Mitral regurgitation of ischemic etiology may be periodic and changes as the left ventricular function changes. Of patients with acute myocardial infarction, 1% die from severe mitral regurgitation from total papillary rupture. The posteromedial papillary muscle is more vulnerable to this phenomenon since it is

Fig. 5.2b. Ventriculotomy closure after aneurysmectomy and coronary bypass using flet strips.

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