The Journal of Thoracic and Cardiovascular Surgery
Volume 140, Issue 1 , Pages 252-253, July 2010

Reply to the Editor

  • Yutaka Otsuji, MD

      Affiliations

    • University of Occupational and Environmental Health, Kitakyushu, Japan
    • ,
  • Ryuzo Sakata, MD

      Affiliations

    • Kyoto University, Kyoto, Japan
    • ,
  • Kayoko Kubota, MD

      Affiliations

    • Kagoshima University, Kagoshima, Japan
    • ,
  • Robert A. Levine, MD

      Affiliations

    • Massachusetts General Hospital, Boston, Mass
    • ,
  • Chuwa Tei, MD

      Affiliations

    • Kagoshima University, Kagoshima, Japan

Article Outline

CTSNet classification: 23, 35, 36

 

We appreciate the comments by Drs Shingu and Matsui. Our investigation showed that functional mitral stenosis (MS) after surgical annuloplasty for ischemic mitral regurgitation (MR) is not rare.1, 2 Mechanistically, diastolic leaflet tethering to restrict its opening in the presence of surgical reduction of annular size causes this functional MS.2 The degree of functional MS is proportional to the degree of recurrent MR after the surgery, and both are closely related to subvalvular tethering. Therefore, functional MS and recurrent MR can be interpreted as a single pathophysiology, presenting in diastole and systole as a different form. Procedures to reduce subvalvular tethering seem reasonable to address functional MS and recurrent MR.

In this context, the data presented by Drs Shingu and Matsui are interesting. They compared 2 surgical techniques to address subvalvular tethering by shortening the distance between both sides of the papillary muscle (PM) tips and mitral annulus: technique number 1 to displace the PM tips toward the posterior mitral annulus and technique number 2 to shift the PM tips toward the anterior annulus. The degree of functional MS is significantly less with PM displacement procedure toward the anterior annulus. The favorable results by PM displacement toward the anterior mitral annulus seem reasonable, because the procedure is likely to reduce tethering in both systole and diastole, whereas PM displacement toward the posterior mitral annulus may impair the systolic closure of posterior leaflet and diastolic opening of the anterior leaflet.

The data by Drs Shingu and Matsui suggest the utility and need for procedures to address subvalvular tethering in patients with ischemic MR. Currently reported surgical procedures to address subvalvular tethering are conceptually reasonable and heterogenous.3, 4, 5 A tailored and heterogeneous approach based on preoperative 3-dimensional evaluation of mitral valve geometry seems necessary to address patients' variability. Standardization is also necessary to perform subvalvular procedures in many institutions. This bidirectional improvement in therapeutic approach is required to achieve a favorable outcome in affected patients.

Back to Article Outline

References 

  1. Magne J, Sénéchal M, Mathieu P, Dumesnil JG, Dagenais F, Pibarot P. Restrictive annuloplasty for ischemic mitral regurgitation may induce functional mitral stenosis. J Am Coll Cardiol. 2008;51:1692–1701
  2. Kubota K, Otsuji Y, Ueno T, Koriyama C, Levine RA, Sakata R, et al. Functional mitral stenosis after surgical annuloplasty for ischemic mitral regurgitation: Importance of subvalvular tethering in the mechanism and dynamic deterioration during exertion. J Thorac Cardiovasc Surg. 2010 Jan 30;[Epub ahead of print]
  3. Terai H, Tao K, Sakata R. Surgical treatment for ischemic mitral regurgitation: strategy for a tethered valve. Ann Thorac Cardiovasc Surg. 2005;11:288–292
  4. Messas E, Guerrero JL, Handschumacher MD, Conrad C, Chow CM, Sullivan S, et al. Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation. 2001;104:1958–1963
  5. Kron IL, Green GR, Cope JT. Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation. Ann Thorac Surg. 2002;74:600–601

PII: S0022-5223(10)00328-4

doi:10.1016/j.jtcvs.2010.03.033

Refers to article:

  • How can we prevent functional mitral stenosis after surgery?

    Yasushige Shingu, Yoshiro Matsui
    The Journal of Thoracic and Cardiovascular Surgery July 2010 (Vol. 140, Issue 1, Pages 251-252)

The Journal of Thoracic and Cardiovascular Surgery
Volume 140, Issue 1 , Pages 252-253, July 2010

Article Tools