Effectively treating ischemic mitral regurgitation with chordal cutting in combination with ring annuloplasty and left ventricular reshaping approach.

schemic mitral regurgitation (IMR) is a common complica- tion of ischemic heart disease that often leads to an adverse prognosis after myocardial infarction and coronary revascu- larization.1 The present accepted therapy for IMR is to reduce the annular size, thereby making a deep coaptation zone. The efficacy of chordal cutting for IMR was first reported by Messas and associates2,3 in 2001. Although this method has been described as a simpler approach to reduce tethering in an experi- mental study, we thought that cutting a limited number of critically positioned chordae, which restrict leaflet closure, might be an effective surgical modality for repair of IMR in clinical cases. We herein present the case of a patient who was treated with chordal cutting in combination with ring annuloplasty and an overlapping cardiac volume reduction operation, which is a new clinical ther- apeutic approach for the treatment of IMR. Clinical Summary A 69-year-old man with ischemic cardiomyopathy associated with IMR and atrial fibrillation was admitted to our institute in February 2004. He had previously presented with acute myocardial infarc- tion of the left anterior descending branch in 1992. Percutaneous transluminal coronary angioplasty for the left anterior descending coronary artery has been performed 3 times for restenosis since 1992. Symptoms of both cardiomegaly and congestive heart failure have been progressively worsening since 2000. The patient was readmitted in November 2003 because of acute heart failure, which he experienced 3 times after the introduction of a -blocker. Echocardiography demonstrated an ejection fraction of 26% with severe-to-moderate mitral regurgitation (MR), a dilated mitral annulus (49 41 mm), severe hypokinesis or akinesis of the anteroseptal left ventricular (LV) motion, and a characteristic distortion of the base of the anterior mitral leaflet (AML), which was tethered by strut chordae to form a bend, thereby reducing the coapting surface (Figure 1, A). Preoperative coronary angiography revealed no progression of coronary arterial stenosis or a restenosis at the stenting site.