Reply to the Editor

Abstract

We thank Drs D'Ancona and Pilato for their thoughtful comments. Patients with ischemic cardiomyopathy represent a diverse population who differ in the extent of myocardial ischemia, severity of the left ventricular dysfunction, and severity of functional ischemic mitral regurgitation. A thorough understanding of the extent of ischemic changes is essential for the appropriate planning of surgical therapy. Magnetic resonance imaging has emerged as a powerful diagnostic tool for the comprehensive evaluation of patients with ischemic cardiomyopathy. In our practice, magnetic resonance imaging is routinely used in patients with ischemic cardiomyopathy for the assessment of the severity and distribution of myocardial scarring, as well as the estimation of residual myocardial viability. Severity of ischemic changes determines the choice of surgical therapy. Presence of transmural scarring in the region of the papillary muscles in patients with severe ischemic cardiomyopathy and severe functional mitral regurgitation is a poor prognostic sign indicating advanced disease. Myocardial revascularization and mitral valve repair with an undersized annuloplasty ring in these patients are often associated with the poor outcomes and high incidence of recurrent mitral regurgitation; therefore, alternative therapies, including heart transplantation, should be considered.1Flynn M. Curtin R. Nowicki E.R. Rajeswaran J. Flamm S.D. Blackstone E.H. et al.Regional wall motion abnormalities and scarring in severe functional mitral regurgitation: a pilot cardiovascular study.J Thorac Cardiovasc Surg. 2009; 137: 1063-1070Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar In contrast, in patients with less severe forms of ischemic cardiomyopathy and moderate functional ischemic regurgitation, substantial improvement in functional status and survival can be accomplished with isolated coronary artery bypass grafting.2Penicka M. Linkova H. Lang O. Fojt R. Kocka V. Vanderheyden M. et al.Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass grafting.Circulation. 2009 Sep 28; ([Epub ahead of print])PubMed Google Scholar The addition of dobutamine echocardiography as a functional diagnostic method for identification of recoverable myocardium, as suggested by Drs Ancona and Pilato, could aid in better understanding this complex disease and should be considered as part of a comprehensive diagnostic workup of patients with ischemic cardiomyopathy. This diagnostic algorithm represents a welcome and long-needed shift from “valvulo-centric” to “ventriculo-centric” focus in management of patients with ischemic cardiomyopathy and functional ischemic regurgitation.3Mihaljevic T. Gillinov A.M. Sabik 3rd, J.F. Functional ischemic mitral regurgitation. Myocardial viability as a predictor of postoperative outcome after isolated coronary artery bypass grafting.Circulation. 2009 Sep 28; ([Epub ahead of print])PubMed Google Scholar Regional wall motion abnormalities and scarring in severe functional ischemic mitral regurgitation: A pilot cardiovascular magnetic resonance imaging studyThe Journal of Thoracic and Cardiovascular SurgeryVol. 139Issue 3PreviewTo the Editor: Full-Text PDF