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Ann Thorac Surg 2000;70:776-777
© 2000 The Society of Thoracic Surgeons
Discussion
DR W. RANDOLPH CHITWOOD (Greenville, NC): I know this is a very exciting and interesting paper and I am very impressed by your results. I find it very interesting, and have several questions. You did 88 repairs using this papillary-shortening technique, and I believe this is in 559 patients who had mitral reconstruction. Is that correct?
DR FASOL: That is right.
DR CHITWOOD: Therefore, about a fifth of your patients had ischemic mitral insufficiency requiring shortening. I must say that I am impressed by the number of elongated papillary muscles in Germany. I do a lot of valve repairs. The most common cause of ischemic mitral insufficiency, at least in my experience, is restrictive insufficiency from either regional ischemia or a posterior infarction with type III restriction. How do you assess these patients, with echocardiography? How often do you see patients with the type of insufficiency that I am talking about—type III versus type II? It appears to me that you have a high number of mitral valves that are insufficient from ischemia. How would you respond to that?
DR FASOL: In Bad Neustadt, the Department where the study was performed, we perform about 4,000 open heart operations a year, and about 10% of all are mitral valve cases. We perform about 400 to 450 mitral valve operations every year, and right now over 70% are repair procedures. As I mentioned at the beginning, we encounter a rising number of ischemic mitral valves where ischemia and/or infarct is the reason for causing mitral valve incompetence.
You are right when saying we have a high number of elongated papillary muscles in our study, but I also probably do slightly more mitral valve operations than other centers do. I also stressed that this group of patients I talked about here, where papillary muscle surgery was performed, is a very specific subgroup of ischemic mitral valve patients.
Of course, we assess all patients with echocardiography preoperatively, and as I mentioned before, in about 10% of all ischemic mitral patients we see pathologic papillary muscles requiring papillary muscle repair surgery.
However, I also mentioned the limitations of this technique. In cases of severely altered left ventricular geometry due to ischemia and infarct, we will not achieve successful results with this technique. But for this specific subgroup of ischemic mitral valve patients, our described technique of papillary muscle repair surgery is a very, we think, simple and effective technique.
DR CHITWOOD: There are a lot of elongated papillary muscles for the percentage in your series. How do you select a ring size? How do you judge the length to shorten the muscle? Do you put a smaller ring in these ischemic valves? Do you downsize?
DR FASOL: We actually do not downsize the rings. We just measure the size of the ring and put the ring in. To measure the exact procedure how far you shorten the papillary muscle if you see it is elongated, actually it is a matter of experience. We do a high volume of these cases.
DR CHITWOOD: So you do not use a saline test or ventricular pressurization?
DR FASOL: No.
DR GUS J. VLAHAKES (Boston, MA): In the slide where you enumerated your postoperative results, what was the source of most of the neurologic events? Were these all intraoperative or did this include a certain period of time in follow-up?
DR FASOL: Neurologic events assessed were intraoperative as well as during a postoperative period of 30 days.
Related Article
Ann. Thorac. Surg. 2000 70: 771-777.
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