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J Thorac Cardiovasc Surg 2003;125:S58-S61
© 2003 The American Association for Thoracic Surgery

Editorials

Ischemic mitral regurgitation redux—to repair or to replace?

From the Department of Cardiovascular Surgery, Stanford University School of Medicine, Stanford, Calif.

Received for publication Aug 20, 2001. Accepted for publication Sept 7, 2001. Address for reprints: D. Craig Miller, MD, Department of Cardiovascular Surgery, Stanford University School of Medicine, Falk Cardiovascular Research Center, CV 243, 300 Pasteur Dr, Stanford, CA 94305-5247.

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	Introduction

 

"Most often the entire valve appears normal; ... There is little to fix, yet the valve leaks. ... the valve is structurally normal; it need not be replaced, but currently we do not know how to fix it. ..."

        —L. Henry Edmunds, Jr, 1997 ¹

The pair of articles in this issue of the Journal by Gillinov, ² Grossi, ³ and their colleagues revisits an old and unanswered question: Is it better to repair or replace the leaking mitral valve in patients with coronary artery disease that has caused ischemic mitral regurgitation (IMR)? These two articles bring contemporary clarity to this dilemma and represent a major step forward, but they do not answer all our questions.

This controversy was reignited in 1995 by Lawrence Cohn and his colleagues ⁴ from the Brigham, who reported that the outcome of patients with IMR undergoing mitral repair or mitral valve replacement (MVR) plus coronary artery bypass grafting (CABG) was not so much dependent on the choice of operative procedure per se, but more on the underlying pathophysiology of the IMR and the patient's clinical presentation. This enlightened certain surgeons who had already convinced themselves that repair was better, but also reminded us that the prognosis for these sick patients was markedly suboptimal. Patients with IMR have morphologically normal mitral leaflets and subvalvular apparatus, but the valve can leak badly. Previously, surgeons had not talked a lot about IMR, perhaps because none of our surgical results were particularly good. Subsequently, we learned conclusively in the multicenter SAVE (Survival and Ventricular Enlargement) trial that even a mild degree of mitral regurgitation (MR) portended a substantial excessive risk of cardiovascular mortality within 5 years after acute myocardial infarction, ⁵ even in patients who did not have any overt signs of congestive heart failure at the time of study entry. These . . . [Full Text of this Article]

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