Surgical treatment of functional mitral regurgitation in dilated cardiomyopathy

Functional mitral regurgitation is a significant complication of end-stage cardiomyopathy. Dysfunction of one or more components of the mitral valve apparatus occurs in 39-74% and affects almost all heart failure patients. Survival is decreased in subjects with more than mild mitral regurgitation irrespective of the aetiology of heart failure. The goal of treating functional mitral regurgitation is to slow or reverse ventricular remodelling, improve symptoms and functional class, decrease the frequency of hospitalization for congestive heart failure, slow progression to advanced heart failure [time to transplant] and improve survival. This article reviews the role of mitral valve surgery in patients with heart failure and dilated cardiomyopathy

Lessons from the SYNTAX trial

Despite the fact that CABG is the standard of care for patients with multivessel coronary arteries and/or left main stem stenosis, PCI has become a rival to CABG in patients with multivessel coronary artery disease or left main disease. However, the need for repeat revascularization, in-stent stenosis and thrombosis remain the achilis heal of PCI. SYNTAX trial randomized patients with left main disease and/or three-vessel disease to PCI with TAXus stent or CABG with the concept that PCI is not inferior to CABG. At 1 and 2 years follow up, MACCE was significantly increased in PCI patients mainly attributed to increased rate of repeat revascularization; however, stroke was significantly more with CABG. The composite safety endpoint of death/stroke/MI was comparable between the 2 groups. Therefore the criterion for non-inferiority was not met. What we learn from SYNTAX is that multi disciplinary team approach should be the standard of care when recommending treatment in more complex coronary artery disease. SYNTAX makes interventionists and surgeons come together, it may set the benchmark for MVD revascularization. PCI and CABG should be considered complementary rather than competitive revascularization strategies. There is no substitute for sound clinical judgment that takes into account the patient's overall clinical profile, functionality, co-morbidities, as well as the patient's coronary anatomy. The SYNTAX Score should be utilized to decide on treatment of patients with LM/MVD. Patients with low and intermediate score can be treated with PCI or CABG with equal results. Those with high score do better with CABG. SYNTAX trial showed that 66% of patients with 3VD or LMD are still best treated