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Department of Cardiac Surgery, ZOL – Campus St-Jan, Schiepse Bos 6, Genk 3600, Belgium
(Email: robert.dion{at}zol.be).
The authors [1] have chosen to measure left ventricular reverse remodeling as a reduction in left ventricle end-systolic volume of greater than 15%. This may be a concern because echocardiography is not the best tool to measure ventricular volumes and sphericity.
As in our study [2], the lack of viability data can be considered a limitation; when viable myocardium subsists in a strategically important area of the ventricle, coronary revascularization may have a preponderant influence. On the other hand, when the ejection fraction is lower than 35%, the presence of an implantable cardioverter defibrillator precludes the use of magnetic resonance imaging. In addition, other types of viability measurements are not precise enough to be contributory.
The percentage of responders is lower than in the Leiden series (43.2% vs 58%), but the response is defined as a 15% systolic remodeling; in ventricles that are not overly dilated, maybe no further systolic dilation is also of clinical interest.
As admitted by the authors [1] themselves, the two rings used are not identical. If the authors have undersized both of the rings by two sizes, they were less restrictive with the latter. It might be the explanation of the rather high incidence of recurrent mitral insufficiency in the nonresponder group after 6 months and the four intraoperative annuloplasty failures in the 50 patients who were excluded from the study. Another reason might be the acceptance of a leaflet coaptation of only 5 mm at the end of the procedure instead of the 8 mm that we always want to achieve.
Finally, until now, we never encountered a case in which restrictive annuloplasty failed to cure pure ischemic mitral regurgitation intraoperatively. Of course valve repair in a mixed disease (ie, the association of a degenerative or of a rheumatic valve disease is much more challenging). In case of extreme tenting (more than 1 cm), Calafiore and colleagues [3] and others advocate replacing the mitral valve (bioprosthesis) with preservation of the subvalvular apparatus. But how does one size the prosthesis? Is it the biggest prosthesis possible? Does one then not miss the opportunity to remodel the base of the heart? In addition, if by any chance, the ventricle (reverse) remodels, the patient survival becomes longer than that of the prosthesis.
I would like to commend the authors [1] for their bright analysis of a controversial problem and for their excellent results. I hope that this work, together with ours will pave the way and counteract the growing but regrettable opinion that one should not necessarily correct a moderate IMR, because it would only prolong the operation and not the long-term survival.
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