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Ann Thorac Surg 2006;81:785
© 2006 The Society of Thoracic Surgeons
Harrison Department of Surgical Research, University of Pennsylvania School of Medicine, 313 Stemmler Hall, 36th and Hamilton Walk, Philadelphia, PA 19104-4283
(Email: gormanr{at}uphs.upenn.edu).
Kim and colleagues [1] address the issue of whether or not to treat significant ischemic mitral regurgitation (IMR) in patients requiring surgical myocardial revascularization. The data they present is very interesting and valuable. However, we found their interpretation of these data unwarrantedly biased toward supporting mitral valve repair in these patients.
In the introduction and discussion sections of the article, the authors make the statement that uncorrected IMR is associated with increased risk of late death. The three references supplied by the authors from the 1980s do not support this statement. In fact, we are not aware of any existing reference that definitively demonstrates a survival benefit from the surgical correction of IMR. On the contrary, the best available references strongly suggest that such surgery provides no survival benefit [2–4]. There is no doubt that the presence of IMR is an ominous prognostic sign. However, this fact should not be misinterpreted as evidence that its treatment will improve survival.
The data presented in this article fails to support a survival benefit from the surgical repair of IMR. When the authors considered all patients, irrespective of the degree of IMR, the 5-year survival was 52% in the revascularization alone group and 44% in the revascularization plus repair group. When only patients with severe MR were considered, the 5-year survival was 41% in the revascularization group and 44% in the combined group. None of these differences were statistically significant. These survival rates are consistent with those achieved for heart failure patients who are treated medically [5]. The only statistical difference between the groups with regard to survival was that the combined group had an 11% operative mortality compared with a 4% operative mortality for revascularization alone.
The only reasonable conclusion that we can draw from the data presented in the article is that mitral valve repair does not improve survival in patients with IMR, and that such surgery subjects patients to an unnecessarily increased surgical risk. Recent clinical and laboratory studies support this conclusion [2–4, 6, 7]. This conclusion may be difficult to accept, but it is what the data teaches. As surgeons, we most come to terms with the sobering possibility that IMR may only be a manifestation of a much more devastating and poorly understood disease namely, infarction induced ventricular remodeling.
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