Ann Thorac Surg 2001;71:378-379
© 2001 The Society of Thoracic Surgeons
How to do it
Transaortic approach for the Alfieri stitch
Göran Källner, MDa,
Jan van der Linden, MDa,
Leonidas Hadjinikolaou, MDa,
Dan Lindblom, MDa
a Department of Cardiothoracic Surgery and Anesthesiology, Huddinge University Hospital, Stockholm, Sweden
Accepted for publication June 26, 2000.
Address reprint requests to Dr Källner, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet at Huddinge University Hospital, S-141 86 Huddinge, Sweden
e-mail: goran.kallner{at}thsurg.hs.sll.se
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Abstract
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The management of associated mitral regurgitation in patients undergoing cardiac surgery is controversial. A simple, reliable, and fast repair is advantageous, especially in critically ill patients. We describe a simple method of transaortic edge-to-edge repair in patients with associated mitral regurgitation undergoing aortic valve surgery.
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Introduction
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Mitral regurgitation (MR) is sometimes present as an associated condition in patients undergoing various cardiac surgical procedures. When deciding whether or not to correct the MR, one must consider its severity, hemodynamic significance, and underlying causes, such as aortic valve disease. Moreover, the added operative trauma, including longer cardiopulmonary bypass (CPB) and cross-clamp time, should be taken into consideration. It is well established that mitral valve repair is the preferred treatment for MR. However, for some types of lesions, the proposed repairs are surgically demanding and there is a risk of poor and nonreproducible results. In this context, the edge-to-edge repair developed by Alfieri and associates is a useful technique [1]. In a variety of MR lesions, including ischemic MR, this technique has proved to be simple, fast, and reliable with good midterm results. In addition to the routine transatrial and transseptal approaches, the edge-to-edge repair can be performed through a left ventriculotomy, in association with surgery for left ventricular (LV) aneurysm or LV failure [2]. Transaortic mitral valve replacement has been described in association with aortic root procedures for Marfan’s syndrome [3] or reoperations [4]. We have used the transaortic approach for edge-to-edge repair of the mitral valve in association with aortic valve replacement (AVR) in 4 patients with MR secondary to LV dysfunction. Three patients had combined aortic stenosis/insufficiency, and 1 had an aortic periprosthetic leak. Patient data are presented in Table 1.
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Technique
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The degree of MR was evaluated with echocardiography and LV angiography preoperatively. With the patient under general anesthesia, the mitral valve was again evaluated with transesophageal echocardiography (TEE) immediately preoperatively. MR was graded as severe (4), moderate (3), mild (2), and trace (1) after restitution of preanesthetic blood pressure levels, ie, a systolic blood pressure of more than 150 mm Hg with phenylephrine IV. The heart was exposed through a median sternotomy. Bicaval or two-stage venous drainage was used. The aorta was cross-clamped and cold blood cardioplegia was given retrogradely. The aortic valve was exposed through an oblique aortotomy extending into the noncoronary sinus of Valsalva. After excision of the aortic valve and debridment of the aortic annulus, the mitral valve was inspected. The midpoint (equidistant from the two commissures) of the free edge of the anterior leaflet was identified, and by lifting this area with a nerve retractor, the posterior leaflet was exposed. The corresponding midpoint of the posterior leaflet was also lifted with a nerve retractor (Fig 1). Identification of the midpoints is aided by observing how the cordae fan out from both leaflets to the anterolateral and posteromedial papillary muscles, respectively. The midpoints of the posterior and anterior leaflets were then sutured together using a 4-0 Prolene mattress suture buttressed with autologous pericardium. The suture was placed approximately 5 mm from the free edge of the leaflets. Aortic valve replacement and concomitant procedures were then completed in a routine fashion. After weaning from CPB, the mitral valve was again evaluated with TEE. The position of the Alfieri stitch was registered and the possible remaining MR was again graded. Before discharge, the mitral valve function was again evaluated by transthoracic echocardiography. Intraoperative data are presented in Table 1.
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Fig 1. Alfieri mitral plasty through the aortic valve. (A = anterior mitral leaflet; P = posterior mitral leaflet; L = left aortic sinus; N = noncoronary aortic sinus; R = right aortic sinus.)
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There was no operative mortality. In patient 2, the post-CPB TEE showed residual grade 3 MR and an eccentric position of the stitch. After aortic cross-clamping and opening of the left atrium, it was found that the Alfieri suture was well positioned at the midpoint of the anterior leaflet, but close to the posteromedial commissure in the posterior leaflet. A mechanical mitral valve prosthesis was inserted with preservation of the posterior leaflet. The remaining 3 patients had only trace MR on post-CPB TEE and on the postoperative transthoracic echocardiography before discharge (Table 1).
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Comment
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The described technique offers a simple way of correcting MR without adding significant time or complexity to the procedure. Although a mild to moderate MR associated with significant aortic stenosis usually improves after AVR, there are certainly patients who will benefit from a fast and simple repair. The failure in patient 2 was from insufficient visualization of the posterior leaflet, stressing the necessity of its adequate exposure. In retrospective, a repositioning of the Alfieri stitch would probably have been efficient. The transaortic approach to the mitral valve has been described for mitral valve replacement [3, 4]. We find this approach even more attractive for the Alfieri stitch, which is per se both fast and simple. Thus, the simplicity of the procedure will probably promote a more aggressive correction of concomitant MR and thus eliminate late corrections from remaining MR. Because a more detailed functional analysis of the mitral valve is not possible with this approach, it should probably be reserved for cases where LV dysfunction is the predominant mechanism of lacking coaptation of the mitral leaflets.
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References
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Maisano F., Torraca 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.[Abstract/Free Full Text]
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McCarthy P.M., Starling R.C., Wong J., et al. Early results with partial left ventriculectomy. J Thorac Cardiovasc Surg 1997;114:755-763.[Abstract/Free Full Text]
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Crawford E.S., Coselli J.S. Marfan’s syndrome: combined composite valve graft replacement of the aortic root and transaortic mitral valve replacement. Ann Thorac Surg 1998;45:296-302.[Abstract/Free Full Text]
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Najafi H., Hemp J.R. Mitral valve replacement through the aortic root. J Thorac Cardiovasc Surg 1994;107:1334-1336.[Abstract/Free Full Text]
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