J Thorac Cardiovasc Surg 2003;126:922
© 2003 The American Association for Thoracic Surgery
Mitral valve in ischemic versus idiopathic dilated cardiomyopathy
Eugene A. Grossi, MDa,
Ram Sharony, MDa,
Stephen B. Colvin, MDa
a Department of Surgery, New York University School of Medicine, New York, NY, USA
To the Editor:
The interesting data set reported on by Hueb and coworkers1 in their article "Ventricular Remodeling and Mitral Valve Modifications in Dilated Cardiomyopathy: New Insights From Anatomic Study" has given us some new insights into the pathologic changes seen in ischemic and idiopathic dilated cardiomyopathy (DCM). The differential changes between these two conditions, however, were not fully explored in the article. As compared with the normal heart, the ratio of relative change in posterior leaflet insertion to anterior leaflet insertion is 3.4-fold in ischemic DCM, versus a 1.7-fold with idiopathic etiology. The impact of these pathologic states on the noncongruence of the fibrous annulus and anterior leaflet insertion is also interesting. One can crudely approximate a difference by a right triangle with the long side equal to the fibrous annulus and the hypotenuse equal to the anterior leaflet insertion. In ischemic DCM this distance is decreased 5.4%, whereas in the idiopathic DCM the distance is increased 11.1%. More detailed studies on the relative positional changes of the fibrous bodies with respect to the commissures will determine whether this is an asymmetric process (occurring more at the posterolateral commissure) or a symmetric one (occurring equally at both).
We also take this opportunity to strongly disagree with a conclusion by the authors, "... these anatomic data support the use of complete mitral annuloplasty techniques in DCM."1 Conceptually, an "annuloplasty alone" repair for these disease states is performed by remodeling the annulus to effectively reduce the anteroposterior diameter to improve leaflet coaptation2-4 and not the lateromedial diameter, which does not seem to lead to mitral regurgitation in ischemic DCM models.5 Although the anatomic data in this study demonstrate pathologic increases in both the anterior leaflet insertion and intertrigonal distances, it is not necessary to equate these changes with the need to fixate the anterior border of the annulus. For ischemic disease, the anterior insertion change is relatively minor when compared with posterior elongation, and for idiopathic changes the intertrigonal increase is accompanied by a 20.3% compensatory increase in the anterior leaflet insertion. We strongly advocate that appropriate valve reconstruction can be performed with an aggressive "trigone to trigone" annuloplasty with a device that fixes anteroposterior diameter. With this approach the annuloplasty device is anchored to the trigones, effectively reducing the anteroposterior diameter while still permitting normal dynamic changes along the base of the anterior mitral annulus.6
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References
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- Hueb AC, Jatene FB, Moreira LF, Pomerantzeff PM, Kallas E, de Oliveira SA. Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: new insights from anatomic study. J Thorac Cardiovasc Surg. 2002;124:1216–1224[Abstract/Free Full Text]
- Carpentier AF, Lessana A, Relland JY, Belli E, Mihaileanu S, Berrebi AJ, et al. The "physio-ring:": an advanced concept in mitral valve annuloplasty. Ann Thorac Surg. 1995;60:1177–1186[Abstract/Free Full Text]
- Timek T, Glasson JR, Dagum P, Green GR, Nistal JF, Komeda M, et al. Ring annuloplasty prevents delayed leaflet coaptation and mitral regurgitation during acute left ventricular ischemia. J Thorac Cardiovasc Surg. 2000;119:774–783[Abstract/Free Full Text]
- Timek TA, Lai DT, Tibayan F, Liang D, Daughters GT, Dagum P, et al. Septal-lateral annular cinching abolishes acute ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2002;123:881–888[Abstract/Free Full Text]
- Green GR, Dagum P, Glasson JR, Daughters GT, Bolger AF, Foppiano LE, et al. Mitral annular dilatation and papillary muscle dislocation without mitral regurgitation in sheep. Circulation. 1999;100(19 Suppl):II95–102
- Dagum P, Timek T, Green GR, Daughters GT, Liang D, Ingels NB, et al. Three-dimensional geometric comparison of partial and complete flexible mitral annuloplasty rings. J Thorac Cardiovasc Surg. 2001;122:665–673[Abstract/Free Full Text]
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