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Division of Cardiac Surgery, The Johns Hopkins Hospital, 600 North Wolfe St, Blalock 618, Baltimore, MD 21287-4618
(Email: jconte{at}csurg.jhmi.jhu.edu).
The authors would like to thank Dr Nakamura [1] for the comments on our article [2] and insightful questions that highlight a few of the limitations of our study. Surgical ventricular restoration (SVR) has consistently been shown to improve the symptoms of severe congestive heart failure and serve as a bridge-to-transplantation in the most challenging patient populations [3–7]. Prior studies attempting to compare SVR with coronary artery bypass grafting (CABG) used left ventricular size to create the comparison group [8]. However, as Dr Nakamura points out, the function of the left ventricle and not necessarily its size, serves as the main indicator for SVR. In our study, the "SVR-candidate" group was chosen based on the presence or absence of the following measurements: an anteroseptal infarct, left ventricular enlargement, akinesia or dyskinesia in the anterior wall, acceptable function of the basal portion of the heart and the lateral wall, and near normal right ventricular function. Although viability and myocardial reserve analysis data in the form of magnetic resonance imaging and dobutamine challenged echocardiography is routinely obtained in our SVR patient population, this data is not available for our standard CABG patients who comprised the "SVR-candidate" cohort. The senior author (masked to patient group) retrospectively identified "SVR-candidates" based on ventriculograms and echocardiography. Importantly, the candidate group was identical to our SVR patient cohort with respect to all available measurements, highlighting the importance of evaluation by an experienced physician.
Mitral valve regurgitation (MR) is a common finding in patients with severe congestive heart failure secondary to a dilated ventricle. The longitudinal and transverse elongation of the left ventricle laterally displaces the papillary muscles and increases the interpapillary distance [9]. Thus, the MR in these patients is the result of poor cardiac function and left ventricle dilatation, which are the surgical indications for an SVR procedure. The presence or absence of regurgitation itself has no impact at all on the decision to perform SVR or CABG alone. The SVR is not appropriate in the absence of the previously mentioned indications. We have published an article describing the impact of SVR on MR, in which we showed that patients with mild to moderate MR undergoing SVR were more likely to have an improvement in MR grade than patients undergoing CABG alone [10]. We agree with Dr Nakamura's [1] contention regarding the negative impact of MR and that is why we are aggressive in correcting it. If the degree of MR after the SVR and CABG procedures is greater than 2+, or if there is a component of MR due to annular dilation, our protocol is to re-initiate cardiopulmonary bypass to repair the valve. At the 1-year follow-up in those patients with a preoperative MR grade less than 1+ who did not receive a mitral valve operation, 50% of these patients (7 of 14) progressed to 2+ MR and 21% of these patients (3 of 14) progressed to 3+ MR within the SVR + CABG group. Comparatively, within the CABG group, 36% of patients (4 of 11) progressed to 2+ MR, and 27% of the patients (3 of 11) progressed to 3+ MR (p = 0.17). In addition, 5 patients within the SVR + CABG cohort and 7 patients within the CABG cohort had a preoperative MR grade 
3+, but in both study groups, 4 patients had improved to mild-to-moderate (1+ to 2+) MR intraoperatively by transesophageal echocardiography and therefore no valve procedures were performed. At the 1-year follow-up, only 1 patient in the SVR + CABG group had an MR 3+ compared with the CABG group in which there were 2 deaths and 3 patients with MR 3+ [10].
On behalf of our co-authors, we would again like to thank Dr Nakamura and colleagues [1] for their critique of our article [2].
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