Ann Thorac Surg 2005;79:474
© 2005 The Society of Thoracic Surgeons
INVITED COMMENTARY
Ottavio Alfieri, MD,
Francesco Maisano, MD
Division of Cardiac Surgery, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
A new useful application of the edge-to-edge (E2E) technique is described in this article by Mascagni and colleagues. Four patients affected with mitral regurgitation due to prolapse of the posterior leaflet from chordal rupture had mitral valve repair and developed postrepair systolic anterior motion and left ventricular outflow tract obstruction that were refractory to volume expansion and medical treatment with ß-blockers. All four patients had redundancy of the anterior leaflet as seen in Barlow's disease. Surprisingly, 2 of these patients received a sliding plasty as part of the repair in an attempt to reduce the height of the posterior leaflet and prevent systolic anterior motion with left ventricular outflow tract obstruction. Using the E2E technique mitral valve replacement was avoided, and the normally functioning (no stenosis and no insufficiency) normal valve was preserved. Thus, all the benefits of reconstructive mitral valve surgery were not denied to these 4 patients. Mitral valve replacement would have been highly undesirable in these patients whose lesions were easily amenable to valve repair. Patients are well aware that reconstructive mitral valve surgery offers a totally normal life without restrictions in activity and without anticoagulation, and is clearly better than valve replacement. With these expectations, patients accept surgery in the early phase of the disease, often before occurrence of symptoms.
The effectiveness of the E2E technique in the specific clinical context of refractory postoperative systolic anterior motion allowed the expectations of these 4 patients to be fulfilled. Although the reported follow-up period is short, excellent long-term results can be predicted [1].
It is important to emphasize that the stitch (or stitches) should be placed at least 1 cm away from the free edge of the leaflets to substantially reduce redundancy of the leaflets and prevent protrusion of valve tissue into the left ventricular outflow tract. This principle is consistently applied by us when the E2E repair is used to correct mitral regurgitation in Barlow's disease, in which redundancy of the leaflets is a peculiar feature [2]. In our large experience with Barlow's disease treated by the E2E technique (> 400 cases), postoperative systolic anterior motion requiring valve replacement never has occurred.
The experience reported in this article also suggests use of the E2E repair for idiopathic hypertrophic subaortic stenosis, in which the mitral valve protrudes into the left ventricular outflow tract and is responsible for the pressure gradient and often for symptoms. Although this solution has been sporadically attempted, data are scanty and are definitely not convincing [3].
In an attempt to correct mitral regurgitation before left ventricular dilatation occurs, a higher prevalence of postoperative systolic anterior motion can be expected. The message delivered by this article should be remembered to offer an easy solution to a difficult problem.
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References
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- 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]
- Maisano F, Schreuder JJ, Oppizzi M, et al. 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]
- Bhudia SK, McCarthy PM, Smedira NG, et al. Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings Ann Thorac Surg 2004;77:1598-1606.[Abstract/Free Full Text]
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