Surgery for Severe Ischemic Mitral Regurgitation

To the Editor: Goldstein et al. (Jan. 28 issue)1 report on 2-year outcomes of the Cardiothoracic Surgical Trials Network trial of surgical treatment of severe ischemic mitral regurgitation. The aim of restrictive mitral annuloplasty in patients with this condition is to eliminate mitral regurgitation and provide an adequate surface for coaptation. Proper patient selection is therefore the key to avoiding a risky repeat operation.2,3 Certain echocardiographic criteria (such as coaptation depth, tethering area, left ventricular end-diastolic and end-systolic diameters, posterior leaflet angle, and annular dilatation) and clinical criteria play an important role in determining which patients should undergo an undersized ring annuloplasty.4,5 If patients are not selected properly, recurrent mitral regurgitation and disease progression may occur after undersized annuloplasty for severe ischemic mitral regurgitation. The above-mentioned echocardiographic and clinical criteria will help to identify patients for whom undersized annuloplasty would be appropriate. If these criteria are not met, we think that procedures other than restrictive annuloplasty should be considered, and valve replacement with preservation of the integrity of the subvalvular apparatus may be performed.