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J Thorac Cardiovasc Surg 2008;135:280-282
© 2008 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Aubrey C. Galloway (New York, NY). This was an excellent paper. You should be congratulated on achieving echographic and clinical follow-up over time so that we can draw some significant conclusions. To review a couple of points: 348 patients, about 24%, had Barlow disease by gross pathologic determination. The linearized rate of recurrence of mitral regurgitation was higher clearly in the Barlow population, but you were able to identify certain other risk factors. Most prominently, you showed, similar to what others have shown, that chordal shortening does not work well in Barlow patients and that the absence of an annuloplasty device or use of a flexible annuloplasty device was associated with a higher failure rate. In contrast, you showed improved late results with chordal replacement and rigid devices. Therefore, if you used those "optimal techniques," the late recurrence rate dropped to an acceptable but still significant 2.9% per year over time.

For fibroelastic deficiency, absence of the use of a sliding plasty technique and absence of the use of a rigid ring were predictors of late recurrence, which you did not put in the presentation but did put in your manuscript. You also observed that a billowing anterior leaflet was predictive of late failure in fibroelastic deficiency, which brings me to my first point. It seems that the gross characterization of valve disease into Barlow versus fibroelastic deficiency is probably not that useful or specific a way to fine tune our predictions as to who is at risk for late failure. There is probably a spectrum of disease that we have not figured out that is not apparent by gross visual inspection at the time of surgery. Maybe we need better phenotypic characterizations or even genotypic ways to characterize these valves.

This brings me to the fundamental question: if . . . [Full Text of this Article]