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O. Alfieri, M. De Bonis
The edge-to-edge technique consists of approximating the free edge of the mitral leaflets at the site of regurgitation using separated stitches or a suture. When the regurgitation is centrally located, a double orifice mitral valve results from the procedure.
The extension of the leaflets approximation should be such to abolish mitral regurgitation without producing mitral stenosis.
A prosthetic ring is generally implanted to stabilize the repair. 'The double orifice' procedure has been applied in patients with Barlow's disease and bileaflet prolapse, in patients with isolated anterior leaflet prolapse and in selected patients with cardiomyopathy (either ischemic or idiopathic) and functional mitral regurgitation.
Long-term results have been evaluated.
Barlow's disease with bileaflet prolapse
The double orifice technique has been used as a standardized approach to treat mitral regurgitation due to severe mixomatous disease leading to prolapse of both leaflets in a consecutive series of 423 patients operated from 1991 to 2003. No patient had primary valve replacement for this condition during the same period of time.
Freedom from reoperation was 90±4.4% at 7 year and beyond. Reoperations were significantly more frequently performed in those patients who did not have mitral annuloplasty due to a diffusely and heavily calcified annulus.
Echocardiographic examinations were regularly carried out during the follow-up period and sustained results over time have been documented. An exercise test was performed in 35 patients with successful repair showing a physiological behaviour during exertion in regard to planimetric valve area and pulmonary pressure.
Anterior leaflet prolapse
Segmental anterior leaflet prolapse was treated with a 'double orifice' procedure in 160 patients operated from 1991 to 2003.
Freedom from reoperation was 96±1.74% at 9 years, not significantly different from that obtained in our Institution in patients who had quadrangular resection for posterior leaflet prolapse. 'The double orifice' technique therefore was able to neutralize anterior leaflet prolapse as an incremental risk factor for suboptimal results following mitral valve repair. As a matter of fact, long-term results in patients with anterior leaflet prolapse have been less gratifying compared to posterior leaflet prolapse in many series.
Functional mitral regurgitation
The edge-to-edge technique has been used prospectively as an adjunct to the undersized annuloplasty since 1998 in those patients with dilated cardiomyopathy (either ischemic or idiopathic) in whom the coaptation depth was > 1 cm. Such a coaptation depth was considered to reflect a rather advanced left ventricular remodeling. Patients with a coaptation depth < 1 cm were treated with an undersized annuloplasty alone. The approximation of the leaflets was thought to be beneficial for the following reasons:
- the regurgitant jet is specifically addressed;
- valve closure is facilitated, particularly in the early phase of the systole;
- A "reins effect", counteracting the remodeling process, is obtained.
Recurrence of hemodynamically relevant mitral regurgitation was significantly lower in patients treated with the edge-to-edge compared to those who only had an annuloplasty, although this latter group originally had a less advanced left ventricular remodeling (coaptation depth < 1 cm). In the edge to edge treated group freedom from mitral regurgitation = 3+ was 95.0%±3.4% at 1.5 years while in the group treated with annuloplasty alone was 77±12.1% (P= 0.04).
The analysis of risk factor for mitral valve repair failure showed the absence of the edge-to-edge to be the only significant risk factor (hazard ratio 4.7; 95% CI 1.2-24.1, p=0.03).
