Subvalvular techniques to optimize surgical repair of ischemic mitral regurgitation

Surgical treatment of ischemic mitral regurgitation with reduction annuloplasty is the current standard of practice, yet recurrence rates approaching 30% limit the benefits of repair in this subset of patients. In an effort to improve outcomes, attention has turned to understanding the contribution of leaflet tethering in this disease process. Subvalvular techniques to alleviate leaflet restriction have recently been incorporated into methods of repair.

Parameters of left ventricular remodeling have been quantified as risk factors for recurrence of mitral regurgitation following reduction annuloplasty. Papillary muscle relocation restores the physiologic configuration of the subvalvular apparatus, and results in significantly reduced rates of recurrent mitral regurgitation and adverse cardiac events over time. Secondary chordal cutting or reimplantation results in significantly increased leaflet mobility, decreased severity of recurrent mitral regurgitation, and improved reverse remodeling without adverse effect on left ventricular function.

A superior repair with decreased recurrence of mitral regurgitation and enhanced reversal of left ventricular remodeling is possible when subvalvular techniques are combined with traditional ring annuloplasty. Further understanding of preoperative parameters that predict disease recurrence and inclusion of concomitant subvalvular techniques in this subset of patients will be the next major advance in this field.