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Ann Thorac Surg 2000;69:721
© 2000 The Society of Thoracic Surgeons

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Discussion

Discussion

DR JOSEPH M. CRAVER (Atlanta, GA): Marc, I enjoyed your comments and report and I enjoyed meeting you personally. I have been using this as well as have done mitral repair for about 10 years. I am impressed with the fact that you have a substantial rate of late recurrent mitral valve regurgitation in spite of the fact that the majority of your problems are of degenerative etiology (75% to 80%). This goes against the common idea that if you fix it, it stays fixed.

You report almost 9% who had 3+ or 4+ regurgitation within 5 years and an additional 9% who had 2+. I wonder why you think that is the case? I have reoperated on 1 person with the Cosgrove Annuloplasty System who had accentuation of the anterior-posterior diameter, producing failure of coaptation, who had to be reoperated within 4 months. I did not see explained in your reoperations enough to account for this percentage of patients who had 2+, 3+, or 4+ regurgitation within a 5-year period in spite of the fact that they are still living. I wonder if you have any further ideas? Do you think it is related to the annuloplasty ring flexibility or other technical features?

DR GILLINOV: We assessed durability of mitral valve repair primarily by the event reoperation for recurrent dysfunction, which is precise because it is a time-related event. Among the 10 patients having reoperation, progression of native valve disease was the most common cause of recurrent mitral valve dysfunction. It is a little harder to assess repair durability by the event return of mitral regurgitation because we do not know when that happens. We only know when we recognize it.

We have late echocardiograms in about three-quarters of the people in this series, and it is true that we found 7 patients, or 9%, who by echocardiogram have 3+ or 4+ mitral regurgitation at 4 or 5 years out. The cause of that mitral regurgitation is difficult to discern.

In general, when we have looked at our failed mitral valve repairs, the most common cause has been progression of the native valve disease, particularly for those with rheumatic and degenerative disease. Other causes of failed mitral valve repair are endocarditis, incomplete mitral repair, and technical errors. We previously analyzed more than 1,000 patients with degenerative mitral valve disease and looked at repair durability and causes of failure, and those causes were just as I stated. The 10-year freedom from reoperation in that group was 93%, so the durability of mitral valve repair is not perfect. Annuloplasty technique did not have an impact on durability.

DR GLENN J.R. WHITMAN (Baltimore, MD): By plicating your posterior annulus more, you have an increased area of coaptation which allows the valve to dilate in the future, which will give you a more durable mitral repair. However, if you size the ring perfectly at the time of operation, degenerative valves, with subsequent dilatation these plicated may develop a central leak. Perhaps with this system, rings should be undersized in certain types of valves so that if you measure the valve to 29, you should put a 27 annuloplasty ring in. In this way you may avoid future regurgitation lesions which may occur if you size the ring perfectly on the day of surgery.

DR GILLINOV: We size the annuloplasty band to the anterior leaflet and use the size as measured there. One of the purposes of an annuloplasty is to prevent future annular dilatation, and since in degenerative disease the annular dilatation occurs primarily along the posterior annulus, we think that sizing to the anterior leaflet is correct. If you misplace the ring and do not encompass the posterior annulus from trigone to trigone, you may have later problems. One notable exception is ischemic mitral regurgitation. In ischemic mitral disease, we are getting better results by undersizing the rings.

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