TY - JOUR
AU1 - Vural, Kerem, M.
AU2 - Taşdemir,, Oğuz
AU3 - Kucukaksu, Suha, D.
AU4 - Tarcan,, Onurcan
AB - Partial left ventriculectomy, Cardiomyopathy, Mitral, Heart failure Table 3, as well as Figs. 4 and 5, are comparative charts of preoperative and postoperative data. Since it is obvious that postoperative data can be obtained only from the survivors, all information in those charts (including preoperative LVESV and LVEDV) exclusively reflect the survivors’ data, for comparative purposes. On the other hand, the data presented in the text (abstract and Table 1) are patient demographics, and therefore, concern with the whole patient population (survivors + non-survivors). This fact can be seen easily by examining the values presented in Table 2, where all data is given separately for survivors and non-survivors. Papillary muscle distortion is not a problem when you replace the valve with or without chordal sparing, but it may render repair attempts futile when you try to reconstruct the valve. Although others report excellent results of partial left ventriculectomy (PLV) with valve reconstruction, it is our opinion that efficiently reducing the left ventricular cavity is more important than preserving the valve or its components, namely the anterior papillary muscle (APM). This should result in reduced left ventricular wall-stress, increased cardiac efficiency, prolonged improvement in hemodynamics, as well as lower arrhythmia incidence, which is known to have a dramatic impact on survival expectation. Although experimental as well as clinical studies going back to 1980s pointed out the benefits of preserving subvalvar apparatus in primary mitral valve disease, the value of mitral reconstruction in PLV (as concluded also in Dr Moreira's cited paper) is yet to be defined. Animal experiments on totally different myocardial conditions may not readily be applicable to PLV candidates. These patients differ from standard mitral valve replacement population in many regards, including that mitral regurgitation is not the primary pathology responsible for the cardiac enlargement, but a result of extensive myopathic dilatation. Insufficient resection may lead to sub-optimal early and late consequences. Mitral valve replacement allows for a more liberal resection. Besides, considering the limited survival expectation in PLV candidates, the concerns for avoiding prosthetic valve complications may not necessarily apply in these particular settings. As emphasized at the end of discussion section in our paper, we agree that chordal preservation should possess theoretical advantages to some extent and, at least the posterior leaflet can be preserved when an extensive resection of the lateral wall including the APM is deemed necessary. A comparative study of postoperative exercise tolerance after PLV in cases with and without chordal preservation is currently being designed in our institution. On the other hand, statements like ‘…immediate hemodynamic improvements appear to drive mainly from a reduced severity of mitral regurgitation’ have no scientific background. Beneficial effects of PLV, in either early or late period, cannot be attributed solely to mitral valve surgery. The mechanism of action is thought to relate to improvement in wall tension and myocardial efficiency resulting from effects derived from the Laplace law. Hence the principal mechanism responsible for the beneficial effect of the procedure should be the increase in cardiac effectiveness instead of directly augmenting forward flow. Therefore, the primary goal must be the removal of excessive tissue that burdens the ventricle. Otherwise, the appeal of preserving the APM may become the siren call that compels the surgeon to keep the extent of resection limited. Tricuspid regurgitation amenable to surgical correction is not the only cause of congestive hepatomegaly in this group of patients. Our cases had only trivial secondary tricuspid insufficiency, and we did not repair those valves, expecting the regurgitation regress after unloading the left ventricle. Postoperative clinical and echocardiographic examinations justified our conservative approach to this secondary type of mild tricuspid insufficiency. © 2001 Elsevier Science B.V. All rights reserved. Elsevier Science B.V.
TI - Reply to Idiz et al.: The appeal of preserving anterior papillary muscle should not interfere with satisfactory reduction in partial left ventriculectomy
JF - European Journal of Cardio-Thoracic Surgery
DO - 10.1016/S1010-7940(01)00601-7
DA - 2001-04-01
UR - https://www.deepdyve.com/lp/oxford-university-press/reply-to-idiz-et-al-the-appeal-of-preserving-anterior-papillary-muscle-Wo4AmCikd1
SP - 539
EP - 540
VL - 19
IS - 4
DP - DeepDyve
ER -