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Ann Thorac Surg 2005;79:752
© 2005 The Society of Thoracic Surgeons

Correspondence

Chronic Ischemic Mitral Regurgitation: Toward a Solution or Still an Enigma?

Emmanuel Villa, MD, Pino Fundarò, MD, Andrea Moneta, MD, Francesco Donatelli, MD

University of Milan MultiMedica HospitalVia Vittoria Colonna 1920149 Milan, Italy

To the Editor:

We read with interest the article by Gorman and colleagues [1]. We expected to find experimental evidence to facilitate treatment of chronic ischemic mitral regurgitation (CIMR). Despite many suggestions, however, several questions remain.

Annular area increased and differences during systole and diastole occurred as compared with the preinfarction state. An increase developed from end isovolemic contraction and end systole (see Fig 2A, in the paper by Gorman and colleagues) [1]. Only values of annular area in animals with severe MR are reported, but values from sheep without severe MR also would be useful. Do you have these data? Is it possible to determine when the annular area exhausts coaptation reserve of the leaflet tissue? Do all annular segments stretch simultaneously or do some stretch first?

Dilation of the intertrigonal distance has previously been described. However, this investigation adds value by showing which portion dilates most. We are also interested in the amounts of stretch between segments defined by three transducers and not by just one segment between two transducers.

At present, therapy for CIRM ranges from valve prosthesis to transplantation, but annuloplasty is gaining acceptance. This paper offers some rational basis for complete ring annuloplasty, but we deem this a rash solution. We are all aware of the need for reliable annular reshaping, but it is also desirable to preserve the annular saddle shape and its sphincteric function (to limit leaflet stress and to aid the valvular-ventricular interaction) [2]. An alternative approach to undersized ring is under investigation: it aims to reduce annular circumference by simultaneously restoring the coaptation reserve in exhausted segments [3].

Regarding their analysis of the annular-papillary muscle relationship, we believe their comment is insufficient and many issues are not well developed. The distance between the posterior papillary muscle tip and anterior commissure increased, although it did not change from the distance to the posterior commissure. This latter distance moved paradoxically during the cardiac cycle (see Figs 5 and 6) [1]. Does this movement explain pseudoprolapse of CIMR observed in the posterolateral region of the valve (P3>A3)? Are current and new techniques able to cope with these complex deformations of annulus, papillary muscles, and ventricle? Perhaps the solution to the enigma of chronic ischemic mitral regurgitation is still far off.

Thanks to these valuable investigations, the reader learns of annular distortion, but doubts continue regarding treatment of ventricular remodeling. These are some intriguing insights that may help improve the dismal prognosis of CIMR.


   References
Top
 References
 

  1. Gorman III JH, Gorman RC, Jackson BM, Enomoto Y, St. John Sutton MG, Edmunds Jr LH. Annuloplasty ring selection for chronic ischemic mitral regurgitationlessons from the ovine model. Ann Thorac Surg 2003;76:1556-1563.[Abstract/Free Full Text]
  2. Salgo IS, Gorman III JH, Gorman RC, et al. Effect of annular shape on leaflet curvature in reducing mitral valve stress Circulation 2002;106:711-717.[Abstract/Free Full Text]
  3. Fundaro P, Pocar M, Moneta P, Donatelli F, Grossi A. Posterior mitral valve restoration for ischemic regurgitation Ann Thorac Surg 2004;77:729-730.[Abstract/Free Full Text]




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