Long-Term Results (≤18 Years) of the Edge-to-Edge Mitral Valve Repair Without Annuloplasty in Degenerative Mitral Regurgitation

Abstract

Preoperative, intraoperative, and postoperative data were collected through a hospital database and patients' records. Follow-up data were Background-To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty in degenerative mitral regurgitation (MR). Methods and Results-From 1993 to 2002, 61 patients with degenerative MR were treated with an isolated edge-to-edge suture without any annuloplasty. Annuloplasty was omitted in 36 patients because of heavy annular calcification and in 25 for limited annular dilatation. A double-orifice repair was performed in 53 patients and a commissural edge-to-edge in 8. Hospital mortality was 1.6%. Follow-up was 100% complete (mean length, 9.2±4.21 years; median, 9.7; longest, 18.1). ResultsThe preoperative data of the final study population are reported in Table 1. At admission, 24 (39%) patients were in New York Heart Association (NYHA) class I or II, whereas 37 (61%) patients were in class III. Fifteen patients (24%) were in atrial fibrillation.Mitral regurgitation degree was determined by means of a combination of color Doppler (color flow jet area and vena contracta width) and pulmonary vein flow analysis and classified as mild (1+/4+), moderate (2+/4+), moderate to severe (3+/4+), and severe (4+/4+). Mitral regurgitation was severe (4+/4+) in 34 patients (34/61; 55.7%) and moderate to severe (3+/4+) in the remaining 27 patients (27/61; 44.2%).Transesophageal echocardiography showed that the mechanism of MR was bileaflet prolapse in 28 patients (46%), anterior leaflet prolapse in 11 patients (18%), and a prolapse of the posterior leaflet in 22 patients (36%). Important annular calcification was found in 36 patients (59%). Surgical ProcedureThe MV was approached through a median sternotomy and a standard left atrial incision in all cases. According to the location of the main regurgitant jet, a double-orifice repair was performed in 53 (86.8%) patients and a commissural EE repair in the remaining 8 (13.1%). The paracommissural repair was posteriorly located in 6 patients and anteriorly located in 2 patients. A 4-0 polypropylene continuous suture without pledgets was used in most cases for leaflet approximation, unless the leaflets were thin. In these cases, a 5-0 suture was preferred.In case of annular calcification, the rationale for adopting the EE technique was to correct leaflet lesions with no annular manipulation. Indeed, the main reason for annuloplasty omission was the presence of significantly/severely calcified annulus which was present in 36 patients (36/61; 59%). In the remaining 25 patients (41%), the EE was intentionally performed without a concomitant annuloplasty because the annulus was judged by the surgeon not to be significantly dilated. By avoiding annuloplasty in those cases, also the risk of inducing postoperative mitral stenosis was minimized. Several associated procedures were performed concomitantly with valve repair, including coronary artery revascularization (9 patients), tricuspid annuloplasty (7 patients), ...

Basal Left Ventricular Dilatation and Reduced Contraction in Patients With Mitral Valve Prolapse Can Be Secondary to Annular Dilatation

“…When MR is eliminated by surgical MV leaflet repair, it is controversial whether ring implantation is still necessary. 22 This study may provide an insight for ring implantation even after the elimination of MR with surgical leaflet repair. In addition, MRI study has demonstrated frequent myocardial fibrosis in the LV base in patients with MVP.…”

Comparison of Outcomes of Percutaneous MitraClip Versus Surgical Repair or Replacement for Degenerative Mitral Regurgitation in Octogenarians

“…Indeed, in the surgical experience, a suboptimal repair with residual prolapse and 2þ MR is a well-known predictor of recurrent severe MR. 15 MitraClip repair is a leaflet procedure and lacks annuloplasty, which is fundamental to achieve optimal and durable results in surgery. We recently published our long-term results with the edge-to-edge technique without annuloplasty in the surgical setting, 16 reporting a disappointing freedom from MR recurrence of 64% at 10 years despite an initial optimal result (MR 1). Transcatheter mitral annuloplasty devices are emerging with promising perspectives, and we all look forward to combine the procedures to recreate in the near future a complete surgical percutaneous mitral repair.…”

MitraClip Therapy for Mitral Regurgitation

“…In degenerative MR, the overall long-term results of the surgical edgeto-edge technique without annuloplasty were found to be unsatisfactory by Alfieri and colleagues. 25 Despite the analogy, percutaneous MitraClip therapy has different mechanical effects compared with the surgical Alfieri technique. Percutaneous clipping exerts greater forces on the MV apparatus as compared with the operative technique leading to a decrease in annular area and diameter comparable with surgical or percutaneous annuloplasty.…”