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Ann Thorac Surg 2001;71:1152-1153
© 2001 The Society of Thoracic Surgeons

Invited commentary

^a Section of Cardiac Surgery, The University of Michigan Hospitals, 1500 E Medical Center Dr, 2120D Taubman Center, Box 0344, Ann Arbor, MI 48109, USA

e-mail: sbolling{at}umich.edu

Doctor Calafiore and associates should be congratulated for the results of their series summarized in this manuscript. In this series, they retrospectively analyzed the results of mitral valve surgery in 49 patients with dilated cardiomyopathy over a ten-year period. Their results were quite good with a 30-day mortality of 4% and a 5- and 10-year actuarial survival of 78% and 73%, respectively. The patients also had an improvement in their New York Heart Association heart failure classification. It should be cautioned that this group of patients had a mean preoperative ejection fraction of 27%, which is higher than has been reported in other series of mitral surgery for dilated cardiomyopathies. The authors rightly conclude, as many others now have concluded, that mitral valve surgery in dilated cardiomyopathy can give satisfying survival and palliation results, for these patients who otherwise would do extremely poorly.

In terms of survival and functional status, it is interesting to read in this manuscript that 5 of 29 patients died, for a 17% actual mortality in the mitral valve repair group, versus 6 of 20 deaths, or a 30% actual mortality in the mitral valve replacement group; a significantly higher actual mortality in the mitral valve replacement group versus mitral valve repair. In regards to the actuarial survival, mitral valve repair was 83% versus 70% for mitral valve replacement, and improvement of New York Heart Class Association at 5 years was 76% in mitral valve repair and 65% in mitral valve replacement. All of these numbers hint at a benefit of mitral valve repair over mitral valve replacement in these patients, as has been demonstrated in all other types of mitral valve perturbation. However, as shown by the authors, the key to good results for these patients is the ability to avoid the return of functional mitral regurgitation, which perhaps can be accomplished, as has been shown by others, with an overcorrecting/undersized circumferential ring.

The authors note that their choice of mitral valve repair versus mitral valve replacement was guided by mitral valve coaptation depth or the length of the zone of coaptation. They propose that mitral valve coaptation depth, as a single value alone, mirrors the perturbations of all the abnormal geometry of the heart, and consequently the mitral valve itself. This may be an oversimplification of the complexities of dilated cardiomyopathy. However, from this data, the authors felt that in the extremely dilated hearts, perhaps mitral valve replacement was a better choice, as they had less return of functional mitral regurgitation.

In this series, the authors did not use a circumferential annuloplasty ring, but used a partial annuloplasty technique of either homologous pericardium or a DeVega-like annuloplasty. Although the authors state that there was no late change in the trigone to trigone distance or "dilation" in the patients who had recurrence of functional mitral regurgitation, it is actually the anterior-posterior diameter which changes most severely in these patients. This AP dilation will not be palliated by a partial ringing technique, but is felt to be prevented with the use of an undersized/overcorrecting circumferential ring.

Again the authors are to be congratulated for their excellent survival and functional results in patients who otherwise would be ineligible for treatment except perhaps with transplantation. More excellent, thoughtful and well reported experiences, like this report, in the area of "geometric surgery" for left ventricular failure will further our understanding of this most interesting subject.

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Mitral valve procedure in dilated cardiomyopathy: repair or replacement?

Antonio M. Calafiore, Sabina Gallina, Michele Di Mauro, Filoteo Gaeta, Angela L. Iacò, Stefano D’Alessandro, Valerio Mazzei, and Gabriele Di Giammarco
Ann. Thorac. Surg. 2001 71: 1146-1152. [Abstract] [Full Text] [PDF]

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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): Steven F. Bolling Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bolling, S. F. Search for Related Content PubMed Articles by Bolling, S. F. Related Collections Congestive Heart Failure Valve disease Related Article