Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings

doi:10.1016/j.athoracsur.2003.09.090

The Annals of Thoracic Surgery

Volume 77, Issue 5, May 2004, Pages 1598-1606

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.

https://doi.org/10.1016/j.athoracsur.2003.09.090 Get rights and content

Abstract

Background

Complex mitral regurgitation (MR) jets can make repair challenging; edge-to-edge (Alfieri) repair augments the repertoire of repair techniques. Objectives of this study were to demonstrate causes of MR amenable to edge-to-edge repair and to determine safety, obstructive potential, and durability of edge-to-edge repair.

Methods

From January 1997 to October 2001, 224 patients underwent Alfieri repair. Indications included ischemic cardiomyopathy (n = 143, 64%), myxomatous disease (n = 31, 14%), dilated cardiomyopathy (n = 27, 12%), and hypertrophic obstructive cardiomyopathy (n = 14, 6%). Concomitant ring annuloplasty was performed in 188 patients (84%). Two additional patients had takedown of an Alfieri repair in the operating room for obstruction. Preoperative MR was 4+ in 109 patients (50%) and 3+ in 65 (30%). Postoperative and follow-up mitral gradient and return of MR were assessed using 396 transthoracic echocardiograms and longitudinal analyses.

Results

Hospital mortality was 2% (5 of 224). Mitral valve mean gradient was low (3.7 mm Hg) and nonprogressive (p = 0.7), although peak gradient rose slightly, from mean 8.4 to 10.0 mm Hg (p = 0.01). During the first 3 postoperative months, absence of MR declined to 40%, and prevalence of 3+ MR increased to 14%, then rose slowly thereafter. Fourteen patients—12 within 2 years—underwent mitral valve reoperation, none for stenosis; 7 patients—6 within 2 years—underwent heart transplantation.

Conclusions

Alfieri mitral repair can be used in a variety of settings with a low risk of creating mitral stenosis. However, in ischemic MR, steadily increasing prevalence of moderately severe and severe regurgitation after edge-to-edge repair suggests other techniques are needed.

Section snippets

Patients

From January 1997 to October 2001, 224 patients underwent edge-to-edge mitral valve repair at The Cleveland Clinic Foundation. Patients who had partial left ventriculectomy (Batista procedure), in whom we first used edge-to-edge repair, were excluded; they have been reported previously [6]. The majority of patients had moderately severe or severe MR by preoperative transthoracic echocardiography (Table 1). Those with no or mild MR preoperatively but who showed evidence of systolic anterior

General comments

Data analysis addressed the following questions: (1) Does edge-to-edge repair cause mitral valve obstruction? (2) What is the durability of edge-to-edge repair, particularly in patients with ischemic MR? (3) Does position of edge-to-edge repair on the mitral valve influence durability? (4) What are the risk factors for return of higher grades of MR? (5) What is the survival in these patients?

To address the first question, postoperative transthoracic echocardiograms were analyzed for mean and

Durability

Longitudinal ordinal logistic regression for repeated measurements (SAS PROC GENMOD) was used to analyze the overall evolution of postoperative MR. This analysis revealed a steep change within the first month after edge-to-edge repair. Thus, risk factors for higher grade of MR were sought separately for echocardiographic assessments made within the first month (early) and those made later.

Because of the limited capability of PROC GENMOD to explore multivariable relationships, we initially

Survival

Nonparametric [8] and parametric [9] estimates of survival were performed and the hazard function estimated. (For details, see http://www.clevelandclinic.org/heartcenter/hazard.)

Applicability

Cause of MR in the majority of patients having edge-to-edge mitral repair was ischemic cardiomyopathy (Table 4). However, it was applied to a wide spectrum of patients, including those with degenerative mitral disease, dilated cardiomyopathy, and HOCM (Table 4).

Safety

Forty-eight patients experienced in-hospital postoperative complications: respiratory insufficiency in 30 (13%), septicemia or sepsis in 17 (8%), renal failure in 8 (4%), postoperative bleeding requiring surgical intervention in 8 (4%),

Comment

In general, mitral valve repair is superior to replacement for MR, with lower operative mortality, improved late survival, reduced risk of endocarditis, fewer thromboembolic complications, and better preservation of ventricular function [1]. Alfieri and colleagues [2] report good results in their series of patients undergoing mitral valve repair, but most patients had degenerative (myxomatous) disease. We have been generally satisfied with early and late results of Carpentier-inspired

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In the current study, we present our midterm experience with this procedure. Only 1 edge-to-edge repair in our series had to be abandoned intraoperatively due to a high transvalvular gradient, leading to a procedural success rate of 98%, which is comparable with other series published in the past.23 The most common reason leading to unsatisfactory repair following edge-to-edge repair through the transaortic access is the incorrect identification of P2 segment leading to misplacement of the Alfieri stitch in the posterior mitral leaflet.
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All patients successfully underwent the minimally invasive surgery through the single transaortic approach via right minithoracotomy. At discharge, postoperative peak LVOTPG (18.16 ± 6.41 mm Hg) and interventricular septum thickness (14.33 ± 1.99 mm) were significantly decreased compared with preoperative values (P < .05). All patients had no or trivial mitral regurgitation. The average peak mitral valve pressure gradient was 3.39 ± 1.82 mm Hg. Systolic anterior motion phenomenon disappeared in all patients. During follow-up, peak LVOTPG was 19.27 ± 6.10 mm Hg; average interventricular septum thickness was 14.67 ± 1.87 mm. All patients had no or trivial mitral regurgitation. Average peak mitral valve pressure gradient was 3.04 ± 1.52 mm Hg. No systolic anterior motion phenomenon occurred.
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Original article: cardiovascularEdge-to-edge (Alfieri) mitral repair: results in diverse clinical settings

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients

General comments

Durability

Survival

Applicability

Safety

Comment

Cardiol Clin

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Original article: cardiovascular
Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings