Ann Thorac Surg 2006;81:1617
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Robert Dion, MD
Leids Universitair Medisch Centrum, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, 2333 ZA, the Netherlands
(Email: r.a.e.dion{at}lumc.nl).
The authors [1] conclude that the edge-to-edge technique is not efficacious in preventing recurrent mitral regurgitation or stenosis if performed for peroperative residual mitral regurgitation. However, in my opinion there is another way to interpret the results: in group 1, the edge-to-edge technique is always used after a mitral valve repair, whereas in group 2 the great majority of the valves were primarily repaired by the edge-to-edge technique (ie, a figure of 8-stitch Ethibond [3 x 0] [Johnson & Johnson, Ethicon Inc, Sommerville, NY]). The original Alfieri technique is much more than that: the stitches are broad and reach the base of the secondary chordae of the anterior leaflet to initiate a good coaptation for the rest of the valve. This was certainly not achieved in group 1, also probably because of a relative lack of residual leaflet tissue after the attempt of repair; this would also explain the 10% incidence of mitral stenosis, but it might have been better achieved in group 2, which would explain the striking difference in results.
The authors are comparing these disappointing results with those published by Alfieri. Yet I do not believe that the authors are allowed to compare a "bail-out" technique with a "primary" one; again the amount of leaflet tissue is completely different before and after an attempt to correct a Barlow disease. The authors apply a sophisticated algorithm to identify patients having a high propensity to systolic anterior motion (SAM). It certainly works if we consider that the 20 patients of group 2 only represent 1.2 % of the patients having benefited from mitral valve repair during the same time span. However, in our experience it has been possible to keep the incidence of SAM around 1% without using a "preventive" Alfieri stitch. The height of the posterior leaflet, if excessive, indeed should be reduced from commissure to commissure and not only in the region of P2. Repositioning of the papillary muscle(s) or the use of neochordae in Goretex (W. L. Gore & Associates, Flagstaff, AZ) currently allow the surgeon to decrease the width of the leaflet resection and the extent of annulus plication. The size of the annuloplasty ring should be adapted to the length of the anterior leaflet and even be oversized in presence of Barlow or Marfan disease. When a preoperative SAM is due to an asymmetric hypertrophy of the septum, the anterior leaflet is often paradoxically too short; an alternative to the Alfieri stitch is the debulking of the septal hypertrophy after disinsertion of the anterior leaflet, followed by an enlargement of the anterior leaflet.
The authors have to be congratulated for producing an important article in a difficult surgical field. They have certainly confirmed that the edge-to-edge technique is successful in correcting a post-repair SAM, and they have validated their algorithm for the detection of a risk for a postoperative SAM. Worrisome is their finding that the edge-to-edge technique is less successful when used as a bail out after a failing repair, which is in fact the indication of the edge-to-edge technique for many surgeons. However, is the Alfieri stitch maybe still useful when there is still enough leaflet tissue?
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References
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- Brinster DR, Unic D, D'Ambra MN, Nathan N, Cohn LH. Midterm results of the edge-to-edge technique for complex mitral valve repair Ann Thorac Surg 2006;81:1612-1617.[Abstract/Free Full Text]
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