HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Robert M. Kass Alfredo Trento Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Czer, L. S.C. Articles by Trento, A. Search for Related Content PubMed Articles by Czer, L. S.C. Articles by Trento, A. Related Collections Coronary disease Related Article

Ann Thorac Surg 2006;81:785-786
© 2006 The Society of Thoracic Surgeons

---

Correspondence

Reply

Cedars-Sinai Medical Center, 8700 Beverly Blvd, Room 6215, Los Angeles, CA 90048-1865

(Email: czer{at}csmc.edu).

To the Editor:

We appreciate the comments by Gorman and Gorman [1]. We stated in our introduction that uncorrected mitral regurgitation leads to reduced long-term survival after revascularization [2]. This is supported by the study of Adler and colleagues [3] who examined 2,004 patients with coronary artery bypass graft surgery, and found that uncorrected mitral regurgitation was independently correlated with reduced long-term survival (mortality rate ratio, 1.5 for each increment of angiographic gradation). In the study by Hickey and colleagues [4], the authors make the statement that "increasing severity of mitral regurgitation has a progressively negative impact on survival regardless of treatment." Rankin and colleagues [5] later proposed that "efforts to improve results might be directed toward a more general application of mitral valve reconstruction in this population." However as we also stated, mitral valve surgery may add to the operative risk when combined with revascularization [2]. Because of the competing influences of an adverse effect of uncorrected mitral regurgitation and an increased operative risk associated with mitral valve surgery, the optimal treatment of ischemic mitral regurgitation remains controversial, and is a fruitful area for investigation and further study.

Despite an apparently higher early mortality in the mitral valve repair group, which was no longer significant in patients with 3+ or 4+ mitral regurgitation, the long-term survival did not differ in the group treated with combined mitral valve repair and revascularization when compared with the group treated with revascularization alone. Yet revascularization alone was associated with an infrequent (11%) reduction in mitral regurgitation by 2 grades or more, resulting in an average residual grade of 2.3 ± 0.1 postoperatively (on a scale of 0 to 4+). By comparison, the combined procedure was associated with a frequent (89%) reduction in mitral regurgitation by 2 or more grades, resulting in an average residual grade of 0.9 ± 0.1 postoperatively [2]. We concluded that the combined procedure resulted in less postoperative mitral regurgitation and a similar 5-year survival when compared with revascularization alone.

There is little doubt that patients with ischemic mitral regurgitation remain at high risk for death, regardless of the surgical procedure chosen. Our finding in the Cox analysis that higher early (30-day) mortality was associated with longer pump times suggests a possible avenue to improve surgical results in this high risk group to reduce ischemic time by use of off-pump techniques. Off-pump techniques have the potential to be applied not only to revascularization, but also to mitral valve repair (through the coronary sinus) and to left ventricular reverse-remodeling techniques. These have yet to be explored to their fullest potential intraoperatively in patients with ischemic mitral regurgitation [6].

Of note, increasing severity of ischemic mitral regurgitation has been shown to increase mortality after myocardial infarction [7] and after percutaneous coronary intervention [8]. Percutaneous techniques of mitral valve annuloplasty are under active investigation and may be competitive technologies in the treatment of ischemic mitral regurgitation, alone or in combination with percutaneous intracoronary stent implantation.

	References

Top References

 

1. Gorman RC, Gorman III JH. Why should we repair ischemic mitral regurgitation? (letter) Ann Thorac Surg 2006;81:785.[Free Full Text]
2. Kim Y-H, Czer LSC, Soukiasian HJ, et al. Ischemic mitral regurgitationrevascularization alone versus revascularization and mitral valve repair. Ann Thorac Surg 2005;79:1895-1901.[Abstract/Free Full Text]
3. Adler DS, Goldman L, O'Neil A, et al. Long-term survival of more than 2,000 patients after coronary artery bypass grafting Am J Cardiol 1986;58:195-202.[Medline]
4. Hickey M StJ, Smith LR, Muhlbaier LH, et al. Current prognosis of ischemic mitral regurgitationimplications for future management. Circulation 1988;78(Suppl I)I-51-9.
5. Rankin JS, Hickey M StJ, Smith LR, et al. Ischemic mitral regurgitation Circulation 1989;79(Suppl I)I-116-21.
6. Kumano H, Fumimoto K, Fujii H, Aoyama T, Nishioka T. Beating heart surgery for ischemic mitral regurgitationreport of a case. Kyobu Geka 2005;58:232-234.[Medline]
7. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. Ischemic mitral regurgitationlong-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 2001;103:1759-1764.[Abstract/Free Full Text]
8. Ellis SG, Whitlow PL, Raymond RE, Schneider JP. Impact of mitral regurgitation on long-term survival after percutaneous coronary intervention Am J Cardiol 2002;89:315-318.[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): Robert M. Kass Alfredo Trento Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Czer, L. S.C. Articles by Trento, A. Search for Related Content PubMed Articles by Czer, L. S.C. Articles by Trento, A. Related Collections Coronary disease Related Article