The effectiveness and durability of the central double-orifice technique were assessed in this study. This type of repair can be a useful addition to the surgical armamentarium in mitral valve reconstruction.

Midterm results of this alternative repair technique are promising, considering the high prevalence of complex anatomical lesions. The technique is simple, easily reproducible and rapidly feasible also when mitral exposure is suboptimal.

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Although the mechanism of ischemic mitral regurgitation (MR) is understood, the echocardiographic picture of ischemic MR is not homogeneous. Ninety-two consecutive patients with chronic ischemic MR due to restricted motion were divided into two groups according to tethering pattern: the asymmetric group with predominant posterior tethering of both leaflets (54 patients) and the symmetric one with predominant apical tethering of both leaflets (38 patients). The mitral deformation indexes, LV global (volume, function and sphericity) and local (papillary muscle displacements and regional wall motion score index) remodeling were evaluated. All indexes of global LV remodeling were significantly higher in the symmetric than asymmetric group (all p < 0.0001), such as the posterior and lateral displacement of the anterior papillary muscle (both p < 0.04), the papillary muscle separation and the anterior papillary muscle wall motion index (both p < 0.0001). The origin as well as the direction of the jet was central in all patients of the symmetric group. In the asymmetric one the origin was central in 78% of the cases and arising from the medial commissure in 22% whereas the jet direction was posterior and central in 83% and 17% of patients, respectively. Therefore, it is possible to distinguish at least two subgroups of patients with ischemic MR due to restricted motion on the basis of tethering pattern, different degree of local and global LV remodeling and characteristics of the regurgitant jet.

Chronic ischemic mitral regurgitation (IMR) is a common complication of myocardial infarction and severely affects cardiovascular mortality and morbidity. Multiple pathophysiologic mechanisms, such as left ventricular (LV) remodeling and dysfunction, annular dilation/dysfunction, and mechanical dyssynchrony, are involved in generating IMR, each of them having different weight. However, the prerequisite to initially creating regurgitation is the presence of local or global LV remodeling that alters the geometrical relationship between the ventricle and valve apparatus. In the wide spectrum of patients with chronic IMR, the assessment of some echocardiographic parameters, such as tethering pattern, leaflet motion, origin and direction of the regurgitant jets, allows one to identify different specific subgroups of patients subjected to different therapeutic approaches. The aim of medical and/or surgical therapy is to ameliorate heart failure symptoms, and improve LV remodeling and function and the intermediate/long-term outcome. The targets of surgical MV repair involve annulus, leaflets, chordae and ventricles. The restricted annuloplasty is the most commonly adopted surgical procedure that improves heart failure symptoms but not survival when compared to medical therapy and is also subject to a high incidence of late failure (approximately 30%). There are some preoperative echocardiographic predictors of failure that include valve (degree of valve remodeling, jet characteristics), ventricular (degree of remodeling, diastolic dysfunction) and surgical factors.

AimsTo assess long-term prognosis in patients with functional mitral regurgitation (FMR) and left ventricular (LV) dysfunction, receiving current standard pharmacological therapy. Methods and resultsWe prospectively enrolled 404 consecutive patients (mean age 70.2 + 10 years) with ischaemic (76.5%) and nonischaemic (23.5%) LV dysfunction (ejection fraction 34.4 + 10.8%) and at least mild MR. Results are reported at 4 years' follow-up. Survival free of all-cause mortality was 53% and cardiac death was 74%. Survival free of allcause mortality was 50% (95% CI 35 -72) for patients with moderate MR, 49% (95% CI 27-65) for severe MR, and 64% (95% CI 47-78) for mild MR (P ¼ 0.03). Survival free of cardiac death was 57% (95% CI 38-74) for patients with moderate MR, 55% (95% CI 30-77) for severe MR, and 94% (95% CI 59 -98) for mild MR (P ¼ 0.003). Moderate-to-severe MR [relative risk (RR) 2.7, 95% CI 1.2 -6.1, P ¼ 0.003] was an independent predictor of cardiac death but not of all-cause mortality. Survival free of heart failure (HF) was 32%. Survival free of HF was 20% (95% CI 17-35) for patients with moderate MR, 18% (95% CI 15-32) for severe MR, and 62% (95% CI 45 -72) for mild MR (P ¼ 0.0001). Moderate-to-severe MR (RR 3.2, 95% CI 1.9 -5.2, P ¼ 0.0001) was an independent predictor of HF. ConclusionThe mortality and morbidity of patients with LV dysfunction and FMR remain high despite current standard pharmacological therapy. Moderate-to-severe MR is an independent predictor of cardiac death and HF.--

The double-orifice repair can be used as a standardized approach to treat valve regurgitation due to Barlow disease with low risk and good early and mid-term results.

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