Ann Thorac Surg 2008;85:2088-2089. doi:10.1016/j.athoracsur.2008.03.050
© 2008 The Society of Thoracic Surgeons
Original Articles: Pediatric Cardiac
Invited Commentary
Richard Mainwaring, MD
Division of Cardiac Surgery, Stanford University, Sutter Medical Center, 5275 F St, Sacramento, CA 95819
(Email: mainwar{at}sutterhealth.org).
The authors [1] report their experience with dilated cardiomyopathy and mitral regurgitation in 5 children who then underwent mitral valve surgical repairs. Four of the 5 patients demonstrated a favorable response to mitral valve repair, with 1 patient requiring cardiac transplantation. The authors conclude that "repair of the mitral valve is safe and feasible in children with dilated cardiomyopathy and acquired mitral regurgitation."
There are several limitations of this series that are purely a product of the relative rarity of this situation. These limitations include the small number of patients, the limited duration of follow-up, and the absence of a parallel medical cohort. As a consequence, it is difficult to make any definitive conclusions, and the authors have appropriately softened their own conclusions.
What one would really like to know is whether mitral valve repair benefits these patients relative to the natural history of the disease. Will mitral valve repair reduce the need for transplantation? Does a delay in mitral valve repair place patients at greater risk for needing transplantation and if so, what are the criteria for intervention? There are also some intriguing aspects of cardiac physiology embedded in the authors' data. Specifically, the data demonstrate that mitral valve repair resulted in decreases in left ventricular end-diastolic and left atrial dimensions, which the authors construe as favorable, but at the expense of some decrement in ejection fraction. Will this decrease in ejection fraction result in an "intervened history" that will be better or possibly worse than the natural history of the disease? These questions are currently not able to be answered due to the limitations previously cited.
Having put forth these comments and critiques, the authors should be commended for endeavoring this work. This is a difficult cohort of patients, and one in which the natural history is not very favorable. The fact that they have suggested this treatment modality should open the door to define the appropriate questions and eventually lead to answers. After all, this is how progress is made.
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References
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- Walsh MA, Benson LN, Dipchand AI, et al. Surgical repair of the mitral valve in children with dilated cardiomyopathy and mitral regurgitation Ann Thorac Surg 2008;85:2085-2089.[Abstract/Free Full Text]
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Surgical Repair of the Mitral Valve in Children With Dilated Cardiomyopathy and Mitral Regurgitation
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