**6. Conclusion**

100 Front Lines of Thoracic Surgery

Of the 50 patients treated with the SAVE procedure, 16 underwent papillary muscle approximation. To illustrate the effects of papillary muscle approximation, dimensional parameters and severity of MR are summarized in **Fig. 9**. Preoperative LVESVI was greater in patients repaired by SAVE and papillary muscle approximation than in patients repaired by SAVE alone (174±56 vs. 141±48 ml/m2), but the difference was not significant. The volume reduction rate was also increased by additional papillary muscle approximation (26% vs. 19%). Irrespective of papillary muscle approximation, the severity of MR was

We have reported the results of our surgical treatment of severe patients with ICM and functional MR and described the details of our surgical strategy. Three kinds of SVR technique effectively reduced LV dimension and changed the spherical shape of the LV into an elliptical shape. Concomitant mitral valve surgery decreased the severity of MR during SVR. This combined surgery would contribute to better surgical outcomes for these patients. The final goal of SVR for ICM with functional MR is re-establishment of the geometric balance of the remodeled LV to increase the forward flow by obtaining concentric contraction and decreasing the extent of MR. We detected the akinetic region of the LV with various techniques and excluded it with three kinds of SVR based on the location of the region. Subsequently, the contractile myocardium was connected by the elliptical patch placed on the "contractility trail". Simultaneously, for patients with a dilated posterior LV wall between two papillary muscles, it was approximated during SVR to restore subvalvular geometry beneath the mitral valve. Although there is no gold standard technique for patients with ICM and functional MR, our combined surgery appears to

For patients with ischemic heart disease, SVR has yielded beneficial short-term effects on functional status, exercise performance, long-term results, and quality of life48,49). However, concomitant SVR is still controversial during CABG for these patients48,49,50). Recently, the Surgical Treatment for Ischemic Heart Failure (STICH) trial addressed this question and demonstrated that anatomical change by SVR was not associated with a greater improvement in symptoms or exercise tolerance or with a reduction in the rate of death or hospitalization for cardiac causes50). Patient selection issues and hemodynamic effects of LV volume reduction have been proposed to explain these contradictory results50). Thus, it would be very difficult to conclude anything about the efficacies associated with SVR, even though a large, multicenter, randomized trial such as STICH has been done. Especially for a

More recently, we have suggested the effectiveness of SVR for patients with ICM51). According to our results, SVR is most effective when a >33% volume reduction rate achieves an LVESVI of <90 ml/m2. No long-term benefits occur when SVR induces an LV volume reduction of <15%, leaving a residual LVESVI >90 ml/m2. Although the results also contradict the STICH trial findings, long-term prognosis in ICM would be determined by the relationships between accurate methods for measuring ventricular volume and the

Due to the diverse patient population, it is very difficult to compare the surgical outcomes among clinical studies and trials. Although details of patients' background were

small number of patients with ICM and functional MR, the same would be true.

4. Effects of papillary muscle approximation in the SAVE procedure

improved after SAVE and mitral ring annuloplasty.

achieve the final goal at this moment.

extent of SVR volume reduction.

**5. Discussion** 

SVR for patients with ICM and functional MR requires various surgical combinations depending on the location of the akinetic region, ventricular size, and subvalvular morphology beneath the MV. The surgical strategy is very important to achieve better surgical outcomes for such high-risk patients.
