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

Sunil K Bhudia, Patrick M McCarthy, Nicholas G Smedira, Buu-Khanh Lam, Jeevanantham Rajeswaran, Eugene H Blackstone
Annals of Thoracic Surgery 2004, 77 (5): 1598-606

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.

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