• heart valve diseases

Asking “what do you think about functional mitral regurgitation (MR)?” is a sure way to start a heated debate at any hypothetical joint cardiology—cardiac surgery dinner. Indeed, other than secondary MR is a distinct entity from primary disease and that medical therapy is the first line of treatment, there seems to be unanimous disagreement on everything else—from quantitation (echo vs MRI, proximal isovelocity surface area (PISA) vs other methods, what should be considered severe regurgitation) to the best interventional strategy (percutaneous vs surgical, repair vs replacement). Pausch et al provide new evidence for the role of cardiac surgery with their short-term (1 year) results of relocating both papillary muscles (subannular mitral valve repair) in combination with annuloplasty from the reform-MR prospective multicentre registry.1 This group of highly experienced mitral valve surgeons performed the combined intervention at five sites in Germany. The initial results in 94 patients seem very promising, with a 1.1% in-hospital mortality and a 4.2% rate of recurrent ≥MR at 1 year. The authors must be commended for creating the prospective registry and for their superb surgical skills. Indeed, perioperative mortality was well below the 4.8% predicted by EuroSCORE II and 3.1% by the Society of Thoracic Surgeons. However, a number of unanswered questions were openly discussed by the authors and must be addressed before declaring this surgical technique the optimal approach in patients with ventricular secondary MR.