Presenter: Dr Satoshi Kainuma Dr Robert E. Michler (New York, NY). Dr Kainuma, the American Association for Thoracic Surgery selection committee made an excellent decision in selecting your abstract for oral presentation. The topic is provocative in answering the question of whether multiple percutaneous coronary intervention (PCI) negatively influences clinical outcomes for ischemic mitral regurgitation, and your work could change clinical practice. Now, with the opportunity to carefully review your manuscript, it appears that an answer is close, but not yet definitive. The unifying aspect of the 2 comparison populations that you studied is that they both underwent restrictive annuloplasty for ischemic mitral regurgitation. Apart from this fact, the 2 groups were in fact very different. An operation such as coronary artery bypass grafting (CABG) is a major predictor of survival as is left ventricular ejection fraction. CABG was performed in significantly different numbers in each comparison group, 85% of 211 in the group with one or fewer PCIs, versus 47% of the 98 patients in the group with multiple PCIs. This fact alone may have led to differences in the outcomes measured and served as the primary driver of why the multiple PCI group did less well, in comparison to the single or no PCI group. Moreover, each additional operation performed would likely have influenced the outcomes measured. Because the multiple PCI group included 50% fewer total patients, the influence of these additional procedures may have negatively influenced the results for the group. And, another cofounding variable such as surgical ventricular reconstruction, which is a highly technical and demanding operation, with its own morbidity and mortality, was performed in 61 of the 211 patients with no or 1 PCI and 35 of the 98 patients with multiple PCIs. Was CABG required less frequently in the multiple PCI group because PCI was so successful in reperfusion of the at-risk territory or because the coronary anatomy was inherently bad? Or worse yet, perhaps the PCI—the prior PCI—had inflamed, sclerosed, and narrowed the distal vessel, making it ungraftable in the eyes of the surgeon? Dr Satoshi Kainuma (Suita, Osaka, Japan). Thank you, Professor Michler, for your great comments and important question. I think both are the reasons why patients with multiple PCI groups were not amenable to CABG. I mean that they were more likely to have more severe disease of the vessel, so bypass surgery was difficult. In addition to that, the result of the PCI was excellent for some patients, whereas not in others. So, I guess both factors were the reasons to explain the infrequent rates of concomitant bypass surgery for patients with multiple PCIs. Dr Michler. Was ischemic mitral regurgitation present at the time of the original PCI? And if it was, was the decision to perform a restrictive annuloplasty made because the desire was to avoid bypass surgery or was the belief that it might in and of itself reduce the grade of ischemic mitral regurgitation? Dr Kainuma. Thank you for your great question. Unfortunately, every patient was not evaluated in terms of ischemic mitral regurgitation at the time of the PCI. This is a problem. And secondly, interventionists in Japan are quite aggressive and prefer to do PCI whenever they see the ischemic mitral regurgitation. Probably because they do not consider that CABG is the best coronary revascularization therapy for patients with ischemic mitral regurgitation and myocardial dysfunction. So, Japanese cardiologists and interventionists are well trained in terms of the procedural aspect, but not with patient selection or indication for the PCI, especially for patients with stable coronary artery disease.
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Jul 31, 2024
Anju Murayama + 2
