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Eur J Cardiothorac Surg 2005;28:778
© 2005 Elsevier Science NL

Letter to the Editor

Management of moderate ischemic mitral regurgitation demystified

Yorkhill NHS Trust, Department of Cardiac Surgery, Royal Hospital for Sick Children, Dalnair Street, Glasgow GS 8SJ, UK

Received 12 July 2005; accepted 5 August 2005.

^_* Corresponding author. Tel.: +44 141 201 0269; fax: +44 141 201 9204. (Email: drrajashahzad{at}hotmail.com).

Key Words: Ischemic mitral regurgitation • Coronary artery bypass grafting • Mitral annuloplasty • Mitral valve repair

Hats off to Campwala et al. [1] for demystifying the management of moderate ischemic mitral regurgitation (IMR). Despite all its limitations their study can be deemed as a landmark contribution to the existing literature on management of IMR. Although they have discussed factors predicting regression of IMR after isolated coronary artery bypass grafting (CABG) in the context of 3-4 + IMR yet the findings of their study can be extrapolated to define the optimal management strategy for 2 + IMR which is the most controversial grade of IMR viz a viz intervention on the mitral valve at the time of CABG.

Although most surgeons would agree that severe IMR (3-4+) should be corrected at the time of CABG and that trace to mild IMR (1+) can probably be left alone, the optimal management of moderate IMR (2+) remains controversial [2]. The pathophysiology of IMR is complex, and its presence may be related to several underlying processes that are often difficult to separate in a given patient [3]. Because of its complex pathophysiology and heterogeneous clinical presentation, the proper treatment of IMR is often debated, and the relative utility of revascularization—with and without concomitant mitral valve surgery—in the setting of moderate IMR is uncertain. Those favoring a conservative approach suggest that revascularizing ischemic areas will improve regional wall motion and correct the MR [4]. On the other hand, proponents of more liberal use of mitral annuloplasty in patients with moderate IMR at the time of CABG argue that CABG alone will not correct moderate IMR in many patients, especially those with scarring from myocardial infarction and those with annular and ventricular dilatation [2].

The study by Campwala et al. [1] has once and for all solved this controversy by providing solid predictors of regression of IMR after CABG alone. As pointed out by Campwala et al. [1] regression of IMR is related to left ventricular (LV) size reduction and improvement in LV function. Hence, a corollary of this conclusion will be that in the presence of low ejection fraction and dilated LV, moderate IMR has to be corrected. On the other hand, in the presence of viable hibernating myocardium, adequate revascularization, lack of excessive atherosclerotic burden and preoperative therapy with beta-blockers and ACE-inhibitors perhaps a more conservative approach with revascularization alone may be justified.

References

1. Campwala SZ, Bansal RC, Wang N, Razzouk A, Pai RG. Factors affecting regression of mitral regurgitation following isolated coronary artery bypass surgery. Eur J Cardiothorac Surg 2005;28:104-108.[Abstract/Free Full Text]
2. Aklog L, Filsoufi F, Flores KQ, Chen RH, Cohn LH, Nathan NS, Byrne JG, Adams DH. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation?. Circulation 2001;104(12 Suppl 1):I68-I75.[Medline]
3. Trichon BH, Glower DD, Shaw LK, Cabell CH, Anstrom KJ, Felker GM, O'Connor CM. Survival after coronary revascularization, with and without mitral valve surgery, in patients with ischemic mitral regurgitation. Circulation 2003;108(Suppl 1):II103-II110.[Medline]
4. Christenson JT, Simonet F, Bloch A, Maurice J, Schmziger M. Should a mild to moderate ischemic mitral valve regurgitaion in patients with poor left ventricular function be repaired or not?. J Heart valve Dis 1995;4:484-488.[Medline]

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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shahzad Gull Raja Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Raja, S. G. Search for Related Content PubMed PubMed Citation Articles by Raja, S. G.