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Insertion of papillary muscle instead of left ventricular reduction
Letters to the Editor
statement by Tibayan and associates4 gives supporting evidence for our hypothesis. Other suggestions may also provide alternative explanations for superiority of complete rings relative to partial ones. As Kwon and colleagues1 mentioned, although complete rings are better for the treatment of functional mitral regurgitation, they need further advances in multiple aspects to be considered as the best treatment option, because recurrence rates are still high. We think that the complete rings are quite well in fixing septolateral dimension changes at the annular level; however, they are not adequate for fixing septolateral dimension changes at the equatorial level of the left ventricle. That is why increased preoperative left ventricular dimension with a left ventricular enddiastolic diameter greater than 65 mm is the most accepted preoperative risk factor for higher rate of recurrence after ring annuloplasty in functional mitral regurgitation, as Kwon and colleagues1 mentioned in their article. We believe that brainstorming regarding the underlying mechanism of recurrence will improve our knowledge and understanding of functional mitral regurgitation. Murat Tavlasoglu, MDa Hasan Alper Gurbuz, MDb Ugur Kucuk, MDc Mustafa Kurkluoglu, MDd a Department of Cardiovascular Surgery Diyarbakir Military Medical Hospital Diyarbakir, Turkey b Cardiovascular Surgery Medicana International Ankara Hospital Ankara, Turkey c Department of Cardiology Van Military Medical Hospital Van, Turkey d Department of Cardiovascular Surgery Children’s National Heart Institute 1304
Children’s National Medical Center Washington, DC References 1. Kwon MH, Lee LS, Cevasco M, Couper GS, Shekar PS, Cohn LH, et al. Recurrence of mitral regurgitation after partial versus complete mitral valve ring annuloplasty for functional mitral regurgitation. J Thorac Cardiovasc Surg. 2013;146:616-22. 2. Carpentier A, Adams DH, Filsoufi F. Surgical anatomy and phsiology. In: Carpentier A, Adams DH, Filsoufi F, eds. Carpentier’s reconstructive valve surgery. Philadelphia: Saunders; 2010:27-43. 3. Nielsen SL, Timek TA, Lai DT, Daughters GT, Liang D, Hasenkam JM, et al. Edge-to-edge mitral repair tension on the approximating suture and leaflet deformation during acute ischemic mitral regurgitation in the ovine heart. Circulation. 2001;104(12 Suppl 1):129-35. 4. Tibayan FA, Rodriguez F, Langer F, Zasio MK, Bailey L, Liang D, et al. Annular remodeling in chronic ischemic mitral regurgitation: ring selection implications. Ann Thorac Surg. 2003;76: 1549-54; discussion 1554-5.
http://dx.doi.org/10.1016/ j.jtcvs.2013.05.050
INSERTION OF PAPILLARY MUSCLE INSTEAD OF LEFT VENTRICULAR REDUCTION To the Editor: We congratulate Michler and colleagues1 on their successful surgery and excellent study recently reported online in the Journal. We would also like to highlight some issues. In the article’s Figure E4, A,1 there was no reduction in left ventricular end-systolic volume index (LVESVI)
in patients undergoing coronary bypass grafting (CABG), and left ventricular ejection fraction did not increase either (as seen in the article’s Table 21). Nevertheless, left ventricular ejection fraction did increase significantly in patients with CABG plus surgical ventricular reconstruction (SVR), and we therefore propose that volume reduction is also necessary for the initial CABG-only group. In the article’s Figure E4, B,1 LVESVI could be seen to drop as low as 30 mL/m2 (normal volume) in many patients undergoing CABG plus SVR. So although ischemia was relieved by CABG, some dilatation may remain as a result of the continuation of relative ischemia, according to Laplace’s law. SVR should therefore be expanded to include the mitral annulus and ventricular base. In addition, the existence of cases with a LVESVI drop to 20 mL/m2 in the article’s Figure E4, A,1 leads us to think that an off-pump procedure should be preferred. Instead of left ventricular reduction,2 the insertion of papillary muscle to the ventricular wall could be palpated from outside on the beating heart, and the apex could be plicated by inserting pledgeted sutures anteroposteriorly and mediolaterally at this level. The ventricular cavity thus could be reduced near the base externally (Figure 1).
FIGURE 1. Insertion of pledgeted sutures for external left ventricular plication.
The Journal of Thoracic and Cardiovascular Surgery c November 2013
Letters to the Editor
Ismail Yurekli, MD Mert Kestelli, MD Habib Cakir, MD Department of Cardiovascular Surgery Izmir Ataturk Education and Research Hospital Izmir, Turkey References 1. Michler RE, Rouleau JL, Al-Khalidi HR, Bonow RO, Pellikka PA, Pohost GM, et al; STICH Trial Investigators. Insights from the STICH trial: Change in left ventricular size after coronary artery bypass grafting with and without surgical ventricular reconstruction. J Thorac Cardiovasc Surg. October 27, 2012 [Epub ahead of print]. 2. Athanasuleas CL, Buckberg GD. Surgery for the failing heart after myocardial infarction. Anadolu Kardiyol Derg. 2008;8(Suppl 2):93-100.
http://dx.doi.org/10.1016/ j.jtcvs.2013.05.051
WHICH IS MORE IMPORTANT IN THE POTENTIAL INTERFERENCE ON CARDIOPROTECTION BY REMOTE ISCHEMIC PRECONDITIONING: b-BLOCKERS OR ANESTHETIC CHOICE? To the Editor: We read with great interest the paper from Kottenberg and colleagues,1
FIGURE 1. Metaregression plot of b-blockers (%) on standardized mean difference (SMD) of myocardial biomarkers in coronary artery bypass grafting (coefficient of 0.0258, P ¼ .092). Original data from Zhou and associates.4
recently published online in the Journal. Building on their previous study,2 they have conducted 2 impressive independent works to explore the cardioprotection by remote ischemic preconditioning (RIPC) with isoflurane3 or propofol1 in coronary artery bypass grafting (CABG).1-3 There has always been concern regarding whether b-blockers could interfere with the cardioprotective effect of RIPC. In their fundamental study,2 the mean b-blocker usage rates were 60% in the propofol substudy and 64% in the isoflurane substudy,
and a better preservation of RIPCinduced cardioprotection with isoflurane than propofol was proposed. This difference seems to remain unchanged in the population, however, with higher proportion of b-blocker medication (83% in propofol1 group and 87% in isoflurane).3 Their series of studies indicates that the anesthetic choice is more critical than b-blocker use in the interference of cardioprotection by RIPC. Nevertheless, our group’s recent meta-analysis,4 which included 15 randomized, controlled trials with
TABLE 1. Results in metaregression and subgroup analyses Variables
Coefficient or SMD
Univariate analysis
No. of comparisons
b-blockers (%) (CABG only) b-blockers (%) Volatile agents
11 14 16
Multivariate analysis b-blockers (%) Volatile agents
Coefficient 0.0258 0.0161 0.6617
95% CI
P value
Adjusted R2
0.0052 to 0.0567 0.0028–0.0295 0.0481 to 1.3716
.092 .022 .065
0.22 0.37 0.23 Adjusted R2
Coefficient 14 14
Subgroup analysis b-blockers (%) >75% 75% Volatile agents Volatile Nonvolatile
Adjusted R2 or PDifference value
0.0129 0.4037
0.00234 to 0.0282 0.5019 to 1.3092
.089 .348
0.61 to 0.04 0.26 to 0.61 0.96 to 0.16 0.57 to 0.02 0.41 to 0.19 1.28 to 0.34
.09 .43 .006 .06 .46 .0008
PDifference value
SMD 14 5 9 15 12 4
0.28 0.18 0.56 0.28 0.11 0.81
0.38
.02
.01
Original data from Zhou and associates.4 SMD, Standardized mean difference; CI, confidence interval; CABG, coronary artery bypass grafting.
The Journal of Thoracic and Cardiovascular Surgery c Volume 146, Number 5
1305
statement by Tibayan and associates4 gives supporting evidence for our hypothesis. Other suggestions may also provide alternative explanations for superiority of complete rings relative to partial ones. As Kwon and colleagues1 mentioned, although complete rings are better for the treatment of functional mitral regurgitation, they need further advances in multiple aspects to be considered as the best treatment option, because recurrence rates are still high. We think that the complete rings are quite well in fixing septolateral dimension changes at the annular level; however, they are not adequate for fixing septolateral dimension changes at the equatorial level of the left ventricle. That is why increased preoperative left ventricular dimension with a left ventricular enddiastolic diameter greater than 65 mm is the most accepted preoperative risk factor for higher rate of recurrence after ring annuloplasty in functional mitral regurgitation, as Kwon and colleagues1 mentioned in their article. We believe that brainstorming regarding the underlying mechanism of recurrence will improve our knowledge and understanding of functional mitral regurgitation. Murat Tavlasoglu, MDa Hasan Alper Gurbuz, MDb Ugur Kucuk, MDc Mustafa Kurkluoglu, MDd a Department of Cardiovascular Surgery Diyarbakir Military Medical Hospital Diyarbakir, Turkey b Cardiovascular Surgery Medicana International Ankara Hospital Ankara, Turkey c Department of Cardiology Van Military Medical Hospital Van, Turkey d Department of Cardiovascular Surgery Children’s National Heart Institute 1304
Children’s National Medical Center Washington, DC References 1. Kwon MH, Lee LS, Cevasco M, Couper GS, Shekar PS, Cohn LH, et al. Recurrence of mitral regurgitation after partial versus complete mitral valve ring annuloplasty for functional mitral regurgitation. J Thorac Cardiovasc Surg. 2013;146:616-22. 2. Carpentier A, Adams DH, Filsoufi F. Surgical anatomy and phsiology. In: Carpentier A, Adams DH, Filsoufi F, eds. Carpentier’s reconstructive valve surgery. Philadelphia: Saunders; 2010:27-43. 3. Nielsen SL, Timek TA, Lai DT, Daughters GT, Liang D, Hasenkam JM, et al. Edge-to-edge mitral repair tension on the approximating suture and leaflet deformation during acute ischemic mitral regurgitation in the ovine heart. Circulation. 2001;104(12 Suppl 1):129-35. 4. Tibayan FA, Rodriguez F, Langer F, Zasio MK, Bailey L, Liang D, et al. Annular remodeling in chronic ischemic mitral regurgitation: ring selection implications. Ann Thorac Surg. 2003;76: 1549-54; discussion 1554-5.
http://dx.doi.org/10.1016/ j.jtcvs.2013.05.050
INSERTION OF PAPILLARY MUSCLE INSTEAD OF LEFT VENTRICULAR REDUCTION To the Editor: We congratulate Michler and colleagues1 on their successful surgery and excellent study recently reported online in the Journal. We would also like to highlight some issues. In the article’s Figure E4, A,1 there was no reduction in left ventricular end-systolic volume index (LVESVI)
in patients undergoing coronary bypass grafting (CABG), and left ventricular ejection fraction did not increase either (as seen in the article’s Table 21). Nevertheless, left ventricular ejection fraction did increase significantly in patients with CABG plus surgical ventricular reconstruction (SVR), and we therefore propose that volume reduction is also necessary for the initial CABG-only group. In the article’s Figure E4, B,1 LVESVI could be seen to drop as low as 30 mL/m2 (normal volume) in many patients undergoing CABG plus SVR. So although ischemia was relieved by CABG, some dilatation may remain as a result of the continuation of relative ischemia, according to Laplace’s law. SVR should therefore be expanded to include the mitral annulus and ventricular base. In addition, the existence of cases with a LVESVI drop to 20 mL/m2 in the article’s Figure E4, A,1 leads us to think that an off-pump procedure should be preferred. Instead of left ventricular reduction,2 the insertion of papillary muscle to the ventricular wall could be palpated from outside on the beating heart, and the apex could be plicated by inserting pledgeted sutures anteroposteriorly and mediolaterally at this level. The ventricular cavity thus could be reduced near the base externally (Figure 1).
FIGURE 1. Insertion of pledgeted sutures for external left ventricular plication.
The Journal of Thoracic and Cardiovascular Surgery c November 2013
Letters to the Editor
Ismail Yurekli, MD Mert Kestelli, MD Habib Cakir, MD Department of Cardiovascular Surgery Izmir Ataturk Education and Research Hospital Izmir, Turkey References 1. Michler RE, Rouleau JL, Al-Khalidi HR, Bonow RO, Pellikka PA, Pohost GM, et al; STICH Trial Investigators. Insights from the STICH trial: Change in left ventricular size after coronary artery bypass grafting with and without surgical ventricular reconstruction. J Thorac Cardiovasc Surg. October 27, 2012 [Epub ahead of print]. 2. Athanasuleas CL, Buckberg GD. Surgery for the failing heart after myocardial infarction. Anadolu Kardiyol Derg. 2008;8(Suppl 2):93-100.
http://dx.doi.org/10.1016/ j.jtcvs.2013.05.051
WHICH IS MORE IMPORTANT IN THE POTENTIAL INTERFERENCE ON CARDIOPROTECTION BY REMOTE ISCHEMIC PRECONDITIONING: b-BLOCKERS OR ANESTHETIC CHOICE? To the Editor: We read with great interest the paper from Kottenberg and colleagues,1
FIGURE 1. Metaregression plot of b-blockers (%) on standardized mean difference (SMD) of myocardial biomarkers in coronary artery bypass grafting (coefficient of 0.0258, P ¼ .092). Original data from Zhou and associates.4
recently published online in the Journal. Building on their previous study,2 they have conducted 2 impressive independent works to explore the cardioprotection by remote ischemic preconditioning (RIPC) with isoflurane3 or propofol1 in coronary artery bypass grafting (CABG).1-3 There has always been concern regarding whether b-blockers could interfere with the cardioprotective effect of RIPC. In their fundamental study,2 the mean b-blocker usage rates were 60% in the propofol substudy and 64% in the isoflurane substudy,
and a better preservation of RIPCinduced cardioprotection with isoflurane than propofol was proposed. This difference seems to remain unchanged in the population, however, with higher proportion of b-blocker medication (83% in propofol1 group and 87% in isoflurane).3 Their series of studies indicates that the anesthetic choice is more critical than b-blocker use in the interference of cardioprotection by RIPC. Nevertheless, our group’s recent meta-analysis,4 which included 15 randomized, controlled trials with
TABLE 1. Results in metaregression and subgroup analyses Variables
Coefficient or SMD
Univariate analysis
No. of comparisons
b-blockers (%) (CABG only) b-blockers (%) Volatile agents
11 14 16
Multivariate analysis b-blockers (%) Volatile agents
Coefficient 0.0258 0.0161 0.6617
95% CI
P value
Adjusted R2
0.0052 to 0.0567 0.0028–0.0295 0.0481 to 1.3716
.092 .022 .065
0.22 0.37 0.23 Adjusted R2
Coefficient 14 14
Subgroup analysis b-blockers (%) >75% 75% Volatile agents Volatile Nonvolatile
Adjusted R2 or PDifference value
0.0129 0.4037
0.00234 to 0.0282 0.5019 to 1.3092
.089 .348
0.61 to 0.04 0.26 to 0.61 0.96 to 0.16 0.57 to 0.02 0.41 to 0.19 1.28 to 0.34
.09 .43 .006 .06 .46 .0008
PDifference value
SMD 14 5 9 15 12 4
0.28 0.18 0.56 0.28 0.11 0.81
0.38
.02
.01
Original data from Zhou and associates.4 SMD, Standardized mean difference; CI, confidence interval; CABG, coronary artery bypass grafting.
The Journal of Thoracic and Cardiovascular Surgery c Volume 146, Number 5
1305