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J Thorac Cardiovasc Surg 2002;124:855-856
© 2002 The American Association for Thoracic Surgery

Letters to the Editor

Chronic ischemic mitral regurgitation: Types and subtypes

Pino Fundarò, MD, Marco Pocar, MD, PhD, Francesco Donatelli, MD, Adalberto Grossi, MD

Divisione e Cattedra di Cardiochirurgia, IRCCS Ospedale Maggiore di Milano, Università degli Studi di Milano, Via Francesco Sforza, 35, 20122 Milan, Italy

To the Editor:

We have read with great interest the three contributions concerning ischemic mitral regurgitation (IMR) recently published in the Journal.Go Go 1-3 All authors give the impression that a definition of subgroups of patients is urgently needed to permit uniform reporting, compare surgical results, and tailor the optimal surgical option for each patient. However, different classification schemes are suggested in each article. According to Steven Bolling's well-known statement that "IMR is a ventricular disease, not a valvular disease," we also believe that a more detailed analysis of the different aspects of postinfarction ventricular pathophysiology would be advisable. The proposed classification of chronic IMR is described in Table 1.


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  		Table 1. Chronic functional ischemic mitral regurgitation varieties
 
It is often difficult to give a clear cutoff between "regional" and "global" dysfunction (types 1 and 2), but the distinction appears useful owing to the poorer natural history and less satisfactory surgical outcome in the presence of advanced ventricular remodeling. In this classification, the term "ventricular-papillary dysfunction," introduced by Grossi and coworkers,Go 2 is used in a broader sense. It refers not only to papillary muscle fibrosis, but also to papillary muscle displacement and tethering of mitral cusps (subtype A) and to annular dilation resulting from postinfarction ventricular remodeling (subtype B). In fact, both mechanisms frequently coexist (subtype C): annular dilation is very common in global ventricular-papillary dysfunction, whereas regional dysfunction generally correlates with papillary muscle (usually posteromedial) atrophy or elongation. In this setting, varying degrees of each pathophysiologic mechanism should probably best be addressed by specific surgical repair.

Unlike others,Go 2 we did not include the term "isolated annular dilation" in the classification because, in our opinion, dilation of the mitral anulus appears correlated to left ventricular dysfunction and therefore does not represent the primary cause of regurgitation. Likewise, we only considered "functional regurgitation" subtypes and did not include insufficiency caused by structural damage (ruptured papillary muscle or chordal disinsertion).

This subdivision does not introduce new concepts; rather, it tries to classify all known pathophysiologic mechanisms of chronic functional IMR with the purpose to select patients for specific surgical correction and, most important, compare results of operations in similar subgroups of patients.

References

  1. Miller DC. Ischemic mitral regurgitation redux—To repair or to replace? J Thorac Cardiovasc Surg. 2001;122:1059-62.[Free Full Text]
  2. Grossi EA, Goldberg JD, LaPietra A, Ye X, Zakow P, Sussman M, et al. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg. 2001;122:1107-24.[Abstract/Free Full Text]
  3. Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001;122:1125-41.[Abstract/Free Full Text]



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Ann. Thorac. Surg., February 1, 2006; 81(2): 786 - 787.
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Francesco Donatelli
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