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Ann Thorac Surg 2004;78:73-76
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Edge-to-edge mitral valve repair: the Columbia Presbyterian experience

Aftab R. Kherani, MDa*, Faisal H. Cheema, MDa, Jennifer Casher, BAa, Jennifer M. Fal, BAa, Christopher J. Mutrie, MDa, Jonathan M. Chen, MDa, Jeffrey A. Morgan, MDa, Deon W. Vigilance, MDa, Mauricio J. Garrido, MDa, Craig R. Smith, MDa, Mehmet C. Oz, MDa

a Department of Cardiothoracic Surgery, Columbia-Presbyterian Medical Center, New York, New York, USA

Accepted for publication August 28, 2003.

* Address reprint requests to Dr Kherani, Division of Cardiothoracic Surgery, College of Physicians and Surgeons, Columbia University, 177 Ft Washington Ave, MHB 7GN-435, New York, NY, USA 10032
e-mail: khera001{at}mc.duke.edu


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
BACKGROUND: The edge-to-edge mitral valve repair, first described by Alfieri in 1995 treats mitral regurgitation when standard reparative techniques are difficult, unlikely to succeed, or have failed. This study examines one institution's medium-term experience with this procedure.

METHODS: This study involved patients undergoing edge-to-edge mitral valve repair at a single institution from 1997 to 2003. Preoperative and postoperative echocardiograms were compared. Postoperative morbidity was examined including need for reoperation and long-term medical management. Thirty-day survival and long-term actuarial survival were also determined.

RESULTS: Seventy-one patients comprised this study. Mitral regurgitation on echocardiogram went from 3.43 ± 0.86 to 0.39 ± 0.61 (p < 0.001) following repair. Thirty-day mortality was 3 of 71 (4.2%) patients. Actuarial survivals at 24 and 60 months were 84.5% and 58.3%, respectively; adjusted excluding noncardiac death they were 89.5% and 82.3%, respectively. Forty (56.3%) patients had concomitant ring placement and experienced similar survival to those repaired with the bow-tie stitch alone. Home telephone follow-up was conducted, and current medical therapy was determined on 51 patients; 59% were on a ß-blocker, 31% were on an angiotensin-converting enzyme (ACE) inhibitor, 27% were on a diuretic, and 22% were on digoxin. All were New York Heart Association (NYHA) class I or II. Three patients (4.2%) underwent mitral valve reoperation after a mean of 299 ± 429 days. In no case did the bow-tie suture rupture.

CONCLUSIONS: Edge-to-edge mitral valve repair is a valuable tool in the armamentarium available to treat complex cases of mitral insufficiency or as an adjunct to standard repair techniques that fail to achieve an acceptable result.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
The advantages of mitral valve repair over replacement are well established. They include better functional preservation of the ventricle, a decreased thromboembolic complication rate, and a decreased risk of endocarditis, all of which translate to a survival advantage [1]. Mitral valve repair was inaugurated in 1957 [2], but was matured by Carpentier and others in the 1970s. With time, the indications for repair have broadened; some believe that repair is possible in 90% of nonrheumatic cases of mitral insufficiency [3], although nearly 70% of mitral valve operations in the United States are replacements [4]. The increasing popularity of mitral valve repair can be attributed to improvements in both technology and technique, including the development of adjuvant techniques to the traditional quadrangular resection. The development of the edge-to-edge mitral valve approach, pioneered by Fucci and colleagues in 1995 [5], made repair an option for patients with complex disease and has served as a simple yet effective adjunct in cases where standard annuloplasty and related repair techniques are insufficient.

In 1996, we initiated a program incorporating the edge-to-edge repair in select cases. Our first-year experience demonstrated the importance of patient selection as patients with related abnormalities, such as severely fibrotic chordae or ischemic papillary muscles, had complicated postoperative courses. This was an ill population whose disease was defined by much more than just valvular disease. Since this time, we have considered both conditions contraindications to edge-to-edge repair. Following this initial period, we have found the edge-to-edge repair to be a simple yet effective addition to, or substitution for, conventional annuloplasty. This study highlights our medium-term experience with the procedure since the initial 12-month period, during which time we learned what type of patient could best benefit from this intervention.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Patients
A retrospective chart review was conducted on patients who underwent edge-to-edge mitral valve repair at our institution between September 1, 1997 and July 15, 2003. There were 71 patients (44 men, 27 women) with a mean age of 62 ± 1.8 (range, 18 to 92) years. Patients undergoing ventricular assist device (VAD) insertion or Batista operations were excluded, because their natural history was more defined by disease of their native myocardium than the valve repair. Intraoperative, preoperative, and postoperative echocardiograms were compared when available (in 52 of 71 [73%] patients). Mitral regurgitation was characterized as mild [1+], mild-moderate [2+], moderate-severe [3+], or severe [4+].

Telephone follow-up was then conducted to assess the patients' current status and medical regimen. Ninety-one percent (51 of 56) of all living patients were contacted (fifteen had died). In five patients, where the patient or family could not be contacted, the Social Security Death Index was reviewed (found at http://ssdi.genealogy.rootsweb.com/) to determine whether the patient was alive.

Methods
Traditionally, intraoperative transesophageal echocardiography was performed on all patients immediately following the induction of anesthesia [6]. For patients undergoing operations not requiring left atriotomy, the 4-0 Prolene repair suture was placed via a transventricular or transaortic approach. The remaining patients usually underwent a more traditional mitral valve repair with an annuloplasty or quadrangular resection before use of an edge-to-edge suture. In these cases, following placement of the aortic cross-clamp, a saline-filled bulb syringe was used to assess the malfunctioning valve by distending the ventricle. This was repeated following the initial repair. If residual leakage was identified, the suture was placed at the most cephalad point where the leaflets should have met, ensuring the largest possible area of coaptation and resulting in a double orifice valve that resembles a bow-tie. This suture was often at the exact midpoint between the commissures, although mal-coapting leaflets were addressed with paracentrically placed sutures. Before sternal closure, cold saline was injected to confirm competence of the repair and transesophageal echocardiography was performed to confirm satisfactory mitral valve function.

Statistical analysis
Data were represented as frequency distributions and percentages. Values of continuous variables were expressed as a mean + standard deviation (SD). Continuous variables were compared using paired t tests, whereas categorical variables were compared by means of {chi}2 tests. For all analyses, a p value of less than 0.05 was considered statistically significant. Kaplan-Meier analysis was used to calculate survival along with a log-rank p value when comparing groups. All data were analyzed utilizing SPSS 11.5 (SPSS Inc., Chicago, IL).


   Results
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 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
In 40 patients the edge-to-edge repair was performed in conjunction with conventional annuloplasty; in the remaining 31 patients, the bow-tie served as the sole method of mitral valve repair. Concomitant procedures other than mitral valve repair were performed in 46 of 71 patients (Table 1).


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  		Table 1. Concomitant Procedures

 
Following repair, mean mitral regurgitation (MR) decreased from 3.43 ± 0.86 to 0.39 ± 0.61 (n = 46, p < 0.001), mean ejection fraction increased from 36.7 ± 16.8 to 42.8 ± 13.3 (n = 24, p < 0.001), and only one patient had a transmitral gradient of more than 10 mm Hg. Thirty-day mortality was 3 of 71 (4.2%) patients. Actuarial overall survival rates at 24 and 60 months were 84.5% and 58.3% (Fig 1), respectively. A total of 15 patients died (6 with an annuloplasty ring and 9 without) after a mean of 15.2 ± 18.5 (range, 0.1 to 49.4) months; five were known cardiac deaths, six patients died of noncardiac causes (two of cancer, one each of sepsis, respiratory arrest, stroke, and renal failure), and four causes of death were unknown. Survival, when adjusted excluding noncardiac death (assuming that the four individuals who died of unknown causes all had cardiac-related deaths), increased to 89.5% and 82.3% at 24 and 60 months (Fig 1), respectively. Forty (56.3%) patients had concomitant ring placement, which did not significantly affect survival (Fig 2). Home follow-up was conducted with either patients or their families and the current medical therapy was determined on 51 patients. Thirty of 51 (58.8%) patients interviewed by telephone were on a ß-blocker, 16 (31.3%) were on an angiotensin-converting enzyme (ACE) inhibitor, 14 (27.5%) were on a diuretic, and 11 (21.6%) were on digoxin. Four (7.8%) were on triple therapy, comprised of an ACE-inhibitor, a diuretic, and digoxin. All of the living patients contacted were either New York Heart Association class I or II.



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  		Fig 1. The 70-month Kaplan-Meier actuarial survival overall and adjusted for cardiac death. Edge-to-edge mitral valve repair (n = 71).

 


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  		Fig 2. The 70-month Kaplan-Meier actuarial survival of patients undergoing concomitant annuloplasty ring placement compared to patients receiving the bow-tie suture alone. Repair with annuloplasty ring (n = 40) versus without annuloplasty ring (n = 31).

 
Three patients (4.2%) underwent mitral valve reoperation. One was a 79-year-old human who underwent reoperation 7 days after mitral repair with a De Vega annuloplasty and bow-tie suture for moderate to severe mitral regurgitation. The repair was performed in conjunction with an aortic valve replacement. Following the initial procedure, the mitral valve area was noted to be 1.0 cm2 and the patient was taken back to the operating room for removal of the bow-tie stitch. The patient was subsequently noted to have only 1+ mitral regurgitation and remained stable from a cardiac standpoint. The second patient was a 59-year-old human with a history of mitral regurgitation. He underwent transaortic edge-to-edge mitral valve repair and aortic valve replacement, and 26 months later required mitral valve replacement for moderate to severe mitral regurgitation. The final patient, a 45-year-old human, returned to the operating room for mitral valve replacement 99 days after his initial edge-to-edge repair, which was complicated by endocarditis; reoperation in conjunction with antibiotic administration resolved his infection. Overall, there were no cases of bow-tie suture rupture.

Of the 71 patients, 18 (25%) had echocardiograms done at our institution at least 4 weeks following their repair (12 with an annuloplasty ring and 6 without). Overall, these patients had a mean mitral regurgitation of 1.17 ± 1.04 at 259.06 ± 374.63 days following surgery. Mean mitral regurgitation of those with an annuloplasty ring was 1.0 ± 0.95 (at 340.75 ± 436.92 days), compared to 1.5 ± 1.23 (at 95.67 ± 95.63 days), for those without a ring (p = 0.406).


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Success using the edge-to-edge procedure has been demonstrated in cases of mitral insufficiency caused by numerous etiologies [7], including endocarditis [8], degenerative disease, posterior leaflet prolapse, or prolapse of both leaflets [9]. Additionally, this procedure has provided favorable results in treating mitral valve disease caused by Barlow's syndrome, with Maisano and colleagues [10] reporting success (86% freedom from reoperation at 5 years) in their 82-patient series. Operative mortality associated with mitral valve replacement is highest in patients with ischemic mitral regurgitation [11, 12]. In this relatively high-risk population, the edge-to-edge technique has also demonstrated utility [13].

Standard approaches to mitral repair were pioneered in the 1970s and the long-term experience with the procedure in nonrheumatic patients was reported by Braunberger and colleagues [14]. Their experience demonstrated a 20-year Kaplan-Meier survival rate of 48%, which is similar to the survival rate of the normal population of the same age. Thus, when studying the efficacy of a type of mitral valve repair success hinges upon more than favorable survival, which is expected. Freedom from reoperation and quality of life determine success and, in these areas, we found the edge-to-edge repair to prove its value. When standard repair techniques fail, several adjunct techniques have been attempted, including the use of polytetrafluoroethylene substitute chordae tendinae, chordal transposition, chordal shortening, and even the cutting of secondary and tertiary chordae. No long-term results are available for these approaches although favorable early results have been reported in several series [15, 16]. The bow-tie technique facilitates repair of complex mitral valve pathology especially when speed and ease of repair are critical; additionally, it can serve as a valuable adjunct in repairing mitral regurgitation that is noted intraoperatively following standard annuloplasty, without causing obstruction or negatively impacting valve hemodynamics [17].

At our institution, we sometimes use edge-to-edge suture placement for repair of the mitral valve when access via the left atrium is not available; especially in cases of mixed aortic stenosis and significant mitral regurgitation when we believe that aortic valve replacement alone will not address the mitral regurgitation. The technique is also of value for inferior basilar aneurysms when involvement of the papillary muscles is present and some degree of preoperative MR is present. For transatrial approaches, we typically attempt a standard repair first; however, if severe bileaflet prolapse is present, success has been demonstrated with the primary use of this suture rather than posterior quadrangular resection [18]. However, in most cases we use this technique only when recurrent leakage through the leaflets on saline testing is evident together with prolapse of the anterior leaflet over the mitral ring prosthesis. Other centers have been more aggressive in using this approach earlier and for primary MV failure [18] and with increasing experience, we believe this approach may have merit. In particular, as less invasive approaches become more feasible, such as with transthoracic robotic or percutaneous access, the use of innovative solutions offered by this repair become appealing. Nevertheless, several pitfalls should be avoided. First, although we have not experienced primary failure of the bow-tie suture, the repaired valves do sometimes leak. This is especially common if catastrophic injury, such as rupture, has occurred to the papillary muscles. The bow-tie suture tethers together the anterior and posterior leaflets, but if the chordal mechanism underlying both is defective, the repair is more apt to fail. Second, the leaflet mechanisms need to be pliable and of adequate quantity in order to allow wide opening during diastole. If the leaflets are congenitally foreshortened or thickened, as in rheumatic disease, use of the bow-tie suture should be discouraged. Finally, the need for use of a mitral annuloplasty ring in these repairs is unclear. Some centers have historically avoided use of rings in their repairs, although most repairs today involve an annuloplasty. When placement of a ring is cumbersome, we have had reasonable success with sole use of the bow-tie approach. This experience gives us more confidence with isolated placement of an edge-to-edge mitral suture in select cases (eg, in the presence of a calcified mitral annulus), where use of the ring may be difficult. Similarly, use of an isolated suture reduces the foreign body material burden in cases of endocarditis.

The largest reported series is Alfieri and colleagues' [18] 7-year experience with 260 patients. It yielded a 5-year Kaplan-Meier estimated survival of 94.4% and freedom from reoperation of 90.0%. Our results from this, the third-largest reported series, lend further support that this technique is effective in the medium-term with patients not only demonstrating good medium-term survival, which is expected of mitral valve repair, but also a high degree of freedom from reoperation. With careful patient selection, the edge-to-edge repair is a valuable addition to the armamentarium available to surgeons in treating mitral regurgitation.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Yun K.L., Miller D.C. Mitral valve repair versus replacement. Cardiology Clinics 1991;9:315-327.[Medline]
  2. Lillehei C.W., Gott V.L., DeWall R.A., et al. Surgical correction of pure mitral insufficiency by annuloplasty under direct vision. J Lancet 1957;77:446.[Medline]
  3. Galloway A.C., Colvin S.B., Baumann F.G., et al. Long-term results of mitral valve reconstruction with Carpentier techniques in 148 patients with mitral insufficiency. Circulation 1988;78(Suppl I):I97.
  4. Society of Thoracic Surgeons 2002 Database. Found at http://www.cts.org/file/STSNationalDatabaseFall2002ExecutiveSummary.pdf
  5. Fucci C., Sandrelli L., Pardini A., Torracca L., Ferrari M., Alfieri O. Improved results with mitral valve repair using new surgical techniques. Eur J Cardiothorac Surg 1995;9:621-626.[Abstract]
  6. Umana J.P., Salehizadeh B., DeRose J.J., Jr, et al. "Bow-tie" mitral valve repair: an adjuvant technique for ischemic mitral regurgitation. Ann Thorac Surg 1998;66:1640-1646.[Abstract/Free Full Text]
  7. Timek T.A., Nielsen S.L., Liang D., et al. Edge-to-edge mitral repair: gradients and three-dimensional annular dynamics in vivo during inotropic stimulation. Eur J Cardiothorac Surg 2001;19:431-437.[Abstract/Free Full Text]
  8. Totaro P., Tolumello E., Fellini P., et al. Mitral valve repair for isolated prolapse of the anterior leaflet: an 11-year follow-up. Eur J Cardiothorac Surg 1999;15:119-126.[Abstract/Free Full Text]
  9. Maisano F., Torracca L., Oppizzi M., et al. The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg 1998;13:240-246.
  10. Maisano F., Schreuder J.J., Oppizzi M., Fiorani B., Fino C., Alfieri O. The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique. Eur J Cardiothorac Surg 2000;17:201-205.[Abstract/Free Full Text]
  11. Christakis G.T., Kormos R.L., Weisel R.D., et al. Morbidity and mortality in mitral valve surgery. Circulation 1985;72(Suppl 2):120-128.
  12. Olson L.J., Subramanian R., Ackerman D.M., Orszulak T.A., Edwards W.D. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin Proc 1987;62:22-34.[Medline]
  13. Umana J.P., Salehizadeh B., DeRose J.J., Jr., et al. "Bow-tie" mitral valve repair: an adjuvant technique for ischemic mitral regurgitation. Ann Thorac Surg 1998;66:1640-1646.
  14. Braunberger E., Deloche A., Berrebi A., et al. Very long-term results (more than 20 years) of valve repair with Carpentier's techniques in nonrheumatic mitral valve insufficiency. Circulation 2001;104(Suppl I):I8-11.
  15. Tomita Y., Yasui H., Tominaga R., et al. Extensive use of polytetrafluoroethylene artificial grafts for prolapse of bilateral mitral leaflets. Eur J Cardiothorac Surg 2002;21:27-31.[Abstract/Free Full Text]
  16. El Khoury G., Noirhomme P., Verhelst R., Rubay J., Dion R. Surgical repair of the prolapsing anterior leaflet in degenerative mitral valve disease. J Heart Valve Dis 2000;9:75-80.[Medline]
  17. Agricola E., Maisano F., Oppizzi M., et al. Mitral valve reserve in double-orifice technique: an exercise echocardiographic study. J Heart Valve Dis 2002;11:637-643.[Medline]
  18. Alfieri O., Maisano F., De Bonis M., et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg 2001;122:674-681.[Abstract/Free Full Text]



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