Commentary: Another step forward ischemic mitral regurgitation comprehension

Central MessageThe study by Aly and colleagues clearly demonstrates that ischemic mitral regurgitation is a complex disease that deserves valvular and subvalvular surgical approaches.See Article page 48.Ischemic mitral regurgitation (IMR) has been considered easily to treat, for years; indeed, the main surgical approach has been restrictive mitral annuloplasty (RMA), addressing just one of the actors involved in the pathophysiologic pathway leading from acute myocardial infarction to IMR.1Braun J. van de Veire N.R. Klautz R.J. Versteegh M.I. Holman E.R. Westenberg J.J. et al.Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure.Ann Thorac Surg. 2008; 85: 430-436Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar,2Gelsomino S. Lorusso R. De Cicco G. Capecchi I. Rostagno C. Caciolli S. et al.Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation.Eur Heart J. 2008; 29: 231-240Crossref PubMed Scopus (106) Google Scholar Unfortunately, IMR turned out to be more technical demanding, so the results of RMA have been scarce so far.3McGee E.C. Gillinov A.M. Blackstone E.H. Rajeswaran J. Cohen G. Najam F. et al.Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation.J Thorac Cardiovasc Surg. 2004; 128: 916-924Abstract Full Text Full Text PDF PubMed Scopus (526) Google Scholar, 4Michler R.E. Smith P.K. Parides M.K. Ailawadi G. Thourani V. Moskowitz A.J. et al.Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2016; 374: 1932-1941Crossref PubMed Scopus (334) Google Scholar, 5Onorati F. Rubino A.S. Marturano D. Pasceri E. Mascaro G. Zinzi S. et al.Mid-term echocardiographic results with different rings following restrictive mitral annuloplasty for ischaemic cardiomyopathy.Eur J Cardiothorac Surg. 2009; 36: 250-260Crossref PubMed Scopus (14) Google ScholarIn an attempt to improve the durability of mitral valve repair for IMR, many study groups are trying to better elucidate the right mechanisms underlying this disease. Recently, we published some articles6Calafiore A.M. Totaro A. Paparella D. Gaudino M. Prapas S. Mick S.L. et al.Mimicking natural mitral adaptation to ischaemic regurgitation: a proposed change in the surgical paradigm.Eur J Cardiothorac Surg. 2020; 58: 35-39Crossref PubMed Scopus (7) Google Scholar,7Calafiore A.M. Totaro A. Testa N. Sacra C. Castellano G. Guarracini S. et al.The secret life of the mitral valve.J Card Surg. 2021; 36: 247-259Crossref PubMed Scopus (6) Google Scholar where even leaflets and chords postischemic modifications are summarized with relative mechanisms, further supporting the need for valvular and subvalvular approaches to improve outcomes. In this scenario, the animal-model study proposed by the Gorman Cardiovascular Research Group8Aly A.H. Saito Y. Bouma W. Pilla J.J. Pouch A.M. Yushkevich P.A. et al.Multimodal image analysis and subvalvular dynamics in ischemic mitral regurgitation.J Thorac Cardiovasc Surg Open. 2021; 5: 48-60Scopus (2) Google Scholar represents another step toward IMR comprehension. The great strength of this study is having employed a multimodal imaging approach to better understand the dynamics of mitral subvalvular apparatus in IMR. Recently, technology of cardiac imaging has advanced, and patients with cardiovascular disease have become increasing more complex. This has led to the integration of several different imaging techniques with a single aim: to clarify the mechanisms at the basis of the disease to guide treatment and predict prognosis.9Capoulade R. Piriou N. Serfaty J.M. Le Tourneau T. Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation.J Thorac Dis. 2017; 9: S640-S660Crossref PubMed Scopus (12) Google Scholar Aly and coworkers8Aly A.H. Saito Y. Bouma W. Pilla J.J. Pouch A.M. Yushkevich P.A. et al.Multimodal image analysis and subvalvular dynamics in ischemic mitral regurgitation.J Thorac Cardiovasc Surg Open. 2021; 5: 48-60Scopus (2) Google Scholar with this approach are able to demonstrate anterior leaflet area increment, reduction of posteromedial papillary muscle volume, and that the latter muscle mainly displaces horizontally and outward along the intercommissural axis. These findings confirm as IMR, especially high-grade, is the result of an unbalanced process starting after myocardial infarction.6Calafiore A.M. Totaro A. Paparella D. Gaudino M. Prapas S. Mick S.L. et al.Mimicking natural mitral adaptation to ischaemic regurgitation: a proposed change in the surgical paradigm.Eur J Cardiothorac Surg. 2020; 58: 35-39Crossref PubMed Scopus (7) Google Scholar,7Calafiore A.M. Totaro A. Testa N. Sacra C. Castellano G. Guarracini S. et al.The secret life of the mitral valve.J Card Surg. 2021; 36: 247-259Crossref PubMed Scopus (6) Google Scholar,10Kim K. Kaji S. An Y. Yoshitani H. Takeuchi M. Levine R.A. et al.Mechanism of asymmetric leaflet tethering in ischemic mitral regurgitation: 3D analysis with multislice CT.JACC Cardiovasc Imaging. 2012; 5: 230-232Crossref PubMed Scopus (26) Google Scholar With this in mind, lone RMA cannot be the unique choice of treatment for IMR; valvular and subvalvular approaches have to deemed necessary. The study by Aly and colleagues clearly demonstrates that ischemic mitral regurgitation is a complex disease that deserves valvular and subvalvular surgical approaches. The study by Aly and colleagues clearly demonstrates that ischemic mitral regurgitation is a complex disease that deserves valvular and subvalvular surgical approaches. See Article page 48. See Article page 48. Ischemic mitral regurgitation (IMR) has been considered easily to treat, for years; indeed, the main surgical approach has been restrictive mitral annuloplasty (RMA), addressing just one of the actors involved in the pathophysiologic pathway leading from acute myocardial infarction to IMR.1Braun J. van de Veire N.R. Klautz R.J. Versteegh M.I. Holman E.R. Westenberg J.J. et al.Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure.Ann Thorac Surg. 2008; 85: 430-436Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar,2Gelsomino S. Lorusso R. De Cicco G. Capecchi I. Rostagno C. Caciolli S. et al.Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation.Eur Heart J. 2008; 29: 231-240Crossref PubMed Scopus (106) Google Scholar Unfortunately, IMR turned out to be more technical demanding, so the results of RMA have been scarce so far.3McGee E.C. Gillinov A.M. Blackstone E.H. Rajeswaran J. Cohen G. Najam F. et al.Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation.J Thorac Cardiovasc Surg. 2004; 128: 916-924Abstract Full Text Full Text PDF PubMed Scopus (526) Google Scholar, 4Michler R.E. Smith P.K. Parides M.K. Ailawadi G. Thourani V. Moskowitz A.J. et al.Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2016; 374: 1932-1941Crossref PubMed Scopus (334) Google Scholar, 5Onorati F. Rubino A.S. Marturano D. Pasceri E. Mascaro G. Zinzi S. et al.Mid-term echocardiographic results with different rings following restrictive mitral annuloplasty for ischaemic cardiomyopathy.Eur J Cardiothorac Surg. 2009; 36: 250-260Crossref PubMed Scopus (14) Google Scholar In an attempt to improve the durability of mitral valve repair for IMR, many study groups are trying to better elucidate the right mechanisms underlying this disease. Recently, we published some articles6Calafiore A.M. Totaro A. Paparella D. Gaudino M. Prapas S. Mick S.L. et al.Mimicking natural mitral adaptation to ischaemic regurgitation: a proposed change in the surgical paradigm.Eur J Cardiothorac Surg. 2020; 58: 35-39Crossref PubMed Scopus (7) Google Scholar,7Calafiore A.M. Totaro A. Testa N. Sacra C. Castellano G. Guarracini S. et al.The secret life of the mitral valve.J Card Surg. 2021; 36: 247-259Crossref PubMed Scopus (6) Google Scholar where even leaflets and chords postischemic modifications are summarized with relative mechanisms, further supporting the need for valvular and subvalvular approaches to improve outcomes. In this scenario, the animal-model study proposed by the Gorman Cardiovascular Research Group8Aly A.H. Saito Y. Bouma W. Pilla J.J. Pouch A.M. Yushkevich P.A. et al.Multimodal image analysis and subvalvular dynamics in ischemic mitral regurgitation.J Thorac Cardiovasc Surg Open. 2021; 5: 48-60Scopus (2) Google Scholar represents another step toward IMR comprehension. The great strength of this study is having employed a multimodal imaging approach to better understand the dynamics of mitral subvalvular apparatus in IMR. Recently, technology of cardiac imaging has advanced, and patients with cardiovascular disease have become increasing more complex. This has led to the integration of several different imaging techniques with a single aim: to clarify the mechanisms at the basis of the disease to guide treatment and predict prognosis.9Capoulade R. Piriou N. Serfaty J.M. Le Tourneau T. Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation.J Thorac Dis. 2017; 9: S640-S660Crossref PubMed Scopus (12) Google Scholar Aly and coworkers8Aly A.H. Saito Y. Bouma W. Pilla J.J. Pouch A.M. Yushkevich P.A. et al.Multimodal image analysis and subvalvular dynamics in ischemic mitral regurgitation.J Thorac Cardiovasc Surg Open. 2021; 5: 48-60Scopus (2) Google Scholar with this approach are able to demonstrate anterior leaflet area increment, reduction of posteromedial papillary muscle volume, and that the latter muscle mainly displaces horizontally and outward along the intercommissural axis. These findings confirm as IMR, especially high-grade, is the result of an unbalanced process starting after myocardial infarction.6Calafiore A.M. Totaro A. Paparella D. Gaudino M. Prapas S. Mick S.L. et al.Mimicking natural mitral adaptation to ischaemic regurgitation: a proposed change in the surgical paradigm.Eur J Cardiothorac Surg. 2020; 58: 35-39Crossref PubMed Scopus (7) Google Scholar,7Calafiore A.M. Totaro A. Testa N. Sacra C. Castellano G. Guarracini S. et al.The secret life of the mitral valve.J Card Surg. 2021; 36: 247-259Crossref PubMed Scopus (6) Google Scholar,10Kim K. Kaji S. An Y. Yoshitani H. Takeuchi M. Levine R.A. et al.Mechanism of asymmetric leaflet tethering in ischemic mitral regurgitation: 3D analysis with multislice CT.JACC Cardiovasc Imaging. 2012; 5: 230-232Crossref PubMed Scopus (26) Google Scholar With this in mind, lone RMA cannot be the unique choice of treatment for IMR; valvular and subvalvular approaches have to deemed necessary. Multimodal image analysis and subvalvular dynamics in ischemic mitral regurgitationJTCVS OpenVol. 5PreviewThe exact geometric pathogenesis of leaflet tethering in ischemic mitral regurgitation (IMR) and the relative contribution of each component of the mitral valve complex (MVC) remain largely unknown. In this study, we sought to further elucidate mitral valve (MV) leaflet remodeling and papillary muscle dynamics in an ovine model of IMR with magnetic resonance imaging (MRI) and 3-dimensional echocardiography (3DE).