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J Thorac Cardiovasc Surg 2002;124:856
© 2002 The American Association for Thoracic Surgery
Letters to the Editor |
Department of Thoracic/Cardiovascular Surgery, The Cleveland Clinic Foundation, Desk F25, 9500 Euclid Ave, Cleveland, OH 44195
Reply to the Editor:
Fundarò and colleagues address the historically difficult task of creating a universally accepted classification system for ischemic mitral regurgitation (IMR). As they note, multiple systems are used for the description of IMR. In fact, the three articles that Fundarò and coworkers cite,
1-3 all of which appeared in the same issue of the Journal, contain slightly different categorizations for IMR. The most important point, however, is that these three classification systems are actually quite similar to one another. All are based on the mechanism(s) of IMR.
Recent observations have furthered our understanding of the pathophysiology of IMR. In some instances, the mechanisms of IMR are quite complicated; therefore, some precision may be sacrificed as each patient is placed in a single group that specifies the predominant mechanism. Nevertheless, such categorization will facilitate more meaningful communication of the nature of IMR.
The authors of the three articles agree that IMR may be caused by papillary muscle disease or by changes in ventricular and/or annular geometry, the latter resulting in functional IMR. Occasionally, more than one of these mechanisms is operative. Miller's classification system 1 is particularly useful. He suggests that the primary mechanism of IMR generally falls into one of the following categories:
Fundarò and colleagues offer a classification system that is similar to the others mentioned here. However, their distinction between regional and global left ventricular dysfunction does not speak directly to the mechanism of IMR. Rather, it introducesanother type of classification system. In addition, subtype A (papillary muscle atrophy, elongation, or displacement) contains disparate entities with different mechanisms of IMR.
Classification systems have a long history of value in cardiac surgery and medicine in general. They are designed to reflect understanding of the nature of diseases (eg, Miller's classification of IMR), to facilitate guidelines and indications for treatment (eg, American Heart Association guidelines), to allow complex observations to be communicated effectively (eg, nomenclature for heart disease), and to reflect differences in prognosis (eg, cancer staging). Fundarò's classification attempts to reflect three different purposes of classification systems simultaneously: mechanism, indications for operation, and prognosis. This may be too ambitious, given the complex nature of IMR.
We, Miller, and Grossi and colleagues propose classification systems that address clarity in understanding the mechanisms of IMR. Choice of operation based on optimization of prognosis is a far more complex and multifactorial issue that, at present, is not clearly amenable to simple classification.
Given our improved understanding of the mechanisms of IMR, it is time that we adopted a common classification system. We recommend following Miller's lead; his mechanism-based description of IMR permits clear categorization of patients.
References
This article has been cited by other articles:
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  A. F. Corno, J. Horisberger, J. David, and L. K. von Segesser Right atrial surgery with unsnared inferior vena cava Eur. J. Cardiothorac. Surg., July 1, 2004; 26(1): 219 - 220. [Abstract] [Full Text] [PDF]
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