Commentary: Following the game-changers: Are we on the right track now?

Abstract

Repair as the principle is not inappropriate for treating ischemic mitral regurgitation, despite restrictive annuloplasty may not always be a winner. The real issue is, we must do the right repair for the right patient.

A right track stems from the right learning

“…[3][4][5][6] In the CTSN trial, 26.2% of patients who underwent restrictive mitral annuloplasty (RMA) did not have concomitant coronary artery bypass grafting, 7 which offers a biological mechanism to explain the observed advantage in clinical outcomes of subvalvular repair in addition to RMA, matching those who had revascularization. 1,4 In our randomized subvalvular repair trial, all patients had myocardial revascularization. 3 Although revascularization is critical, we believe that criticisms of subvalvular repair procedures may derive from the presence of 22.5% of patients who have mild to moderate MR at a 5-year follow-up.…”

“…Numerous studies have focused on the degree of annular restriction by mitral annuloplasty given the reported risk of stenosis, systolic anterior motion, and recurrent MR in overcorrection or excessive undersizing. [1][2][3][4][5][6][7][8][9] The anterior leaflet enlargement patch as performed by the authors is progressive 10 (Figure 1), provided that there is a marked reduction of tethering forces. 11,12 The forces on the fibrous skeleton of the heart exerted by annular undersizing would counteract the displacement vectors relative to the LV dilation expected in these patients.…”

Update on surgical repair in functional mitral valve regurgitation.

“…48,53 Given that these factors were not considered as inclusion or exclusion criteria for randomization, a crucial bias exists. 50 If these cases and those with a mismatch between the LV and mitral ring size were detected at the time of surgery, consideration should be given to an intervention directed to improving leaflet coaptation at valvular (e.g., leaflet augmentation plus true-size annuloplasty, [17,54] Figures 1 and 2) and subvalvular levels (e.g., papillary muscle approximation or relocation) [55,56] . Since the life-expectancy of patients undergoing replacement is endangered by the incremental risk of thromboembolic/hemorrhagic and prostheses-related events, well-designed RCTs without significant operational flaws are required to reconfirm the role of surgical MV repair in treating severe FMR.…”

“…Although mitral replacement could provide durable FMR correction results, it makes little sense to routinely replace "structurally normal" valves with artificial prostheses. 17 Accordingly, the questions that have befuddled cardiac surgeons are: (1) If FMR is the consequence of LV dilatation and dysfunction, can surgical interventions that target the MV still be effective in certain patients? (2) How to select the right patients that would authentically benefit from surgical repair?…”

Update on surgical repair in functional mitral regurgitation

“…Although mitral replacement could provide durable FMR correction results, it makes little sense to routinely replace "structurally normal" valves with artificial prostheses. 17 Accordingly, the questions that have befuddled cardiac surgeons are: (1) If FMR is the consequence of LV dilatation and dysfunction, can surgical interventions that target the MV still be effective in certain patients? (2) How to appropriately select patients that would authentically benefit from surgical repair?…”