Restrictive ring annuloplasty for chronic ischemic mitral regurgitation

摘要

I read with great interest the article by Ay and colleagues. Firstly, I should like to congratulate the authors for this fine work. They showed an excellent outcome in patients with chronic ischemic mitral regurgitation (CIMR) undergoing restrictive mitral annuloplasty plus P2 plication. However, I believe that the surgical technique used in these cases must be analyzed in depth. It is well known that CIMR is mainly due to 3-dimensional structural distortion of the mitral valve (MV). At the same time, posteroinferior left ventricular remodeling causing a tethering effect on the P2 segment of the MV is the culprit in this dysfunction. In an attempt to address this issue, Bach and Bolling described for the first time the concept of restrictive MV annuloplasty. Under-sizing by two sizes from the appropriate size, a small ring size is used (usually 28?mm or 30?mm). In other words, one performs an anterior advancement of the closure line of both MV leaflets. Certainly, this may not the best choice to treat the CIMR, but this is the easiest and safest reproducible technique. Important recurrence of mitral regurgitation has been observed in up to 30% of cases at med- and long-term follow-up after surgery. Nevertheless, we have to be careful in patient selection. One of the independent factors predicting the recurrence of MR is a preoperative posterior leaflet MV angle >45 degrees. The greater the angle, the higher the recurrence of MV regurgitation. There are some other preoperative parameters related to this recurrence, such as tenting area and coaptation depth.4 Of note is that an asymmetric tethering pattern is often shown in this type of patient.5 Consequently, given the circumstances above, the posterior leaflet angle is the most important predictor of this recurrence.