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Ann Thorac Surg 2000;69:1640
© 2000 The Society of Thoracic Surgeons

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Correspondence

Moderate mitral insufficiency in coronary disease: when should it be corrected?

^a Divisione di Cardiochirurgia, Ospedale "Luigi Sacco", Via G. B. Grassi, 74, 20157 Milan, Italy

To the Editor

We wish to draw attention to a serious problem in the report by Durante and associates [1] regarding the effect of mitral regurgitation (MR) on late outcome after myocardial revascularization.

We entirely agree with the authors that the correct treatment of MR in association with coronary artery bypass remains one of the most challenging problems in cardiac operations. In our experience we believe that the ischemic cause of MR is the most important variable that could result in suboptimal results on early and late survival. In the last decade, the operative approach to moderate ischemic MR has evolved from myocardial revascularization alone to surgical revascularization combined with mitral operation. The decision to operate on the mitral valve is still more difficult especially in patients with multivessel coronary disease. In any case, the issue of concern is to determine what exactly is "moderate" MR. There may be a discrepancy in the quantification of MR by color Doppler and angiography. In such cases, the decision to operate on the mitral valve can be made only after carefully reviewing the clinical features and hemodynamic data. What we have done in such cases which helps us in the decision making is a simple test proposed by Rankin and colleagues [2]. These authors stress the importance of the influence of left ventricular volume loading on the severity of MR; if transesophageal-echocardiographic findings show an increase of MR after elevating left atrial pressure above 15 to 18 mm Hg, they proceed with a valve operation.

We used this test in our limited experience [3]; mitral valve repair or replacement was performed on 55 patients with chronic ischemic MR but MR was severe in only 24 patients (43.6%). In 31 patients (56.3%) MR was moderate. In all cases the Rankin test was used to establish the correct indication for operation.

We believe this simple but useful test has the advantage of allowing a more dynamic estimation of the mitral valve function providing an important option in borderline cases.

References

1. Durante I.G., Shen Y., MacDonald M.J., et al. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone. Ann Thorac Surg 1999;68:426-430.[Abstract/Free Full Text]
2. Rankin J.S., Hickey M.S., Smith L.R., et al. Ischemic mitral regurgitation. Circulation 1989;79(Suppl 1):116-121.[Abstract/Free Full Text]
3. Scrofani R., Cialfi A., Ravagnan S., Fundaro’ P. Il trattamento chirurgico dell’insufficienza mitralica ischemica cronica. G Ital Cardiol 1999;29:418-423.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carlo Antona Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Scrofani, R. Articles by Antona, C. Search for Related Content PubMed Articles by Scrofani, R. Articles by Antona, C.