Transaortic Edge-To-Edge Repair for Functional Mitral Regurgitation during Aortic Valve Replacement: A 13-Year Experience

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> The study evaluated the feasibility of a transaortic edge-to-edge mitral valve repair (Alfieri stitch) for moderate or greater (≥2+) functional mitral regurgitation (MR) in high-risk patients undergoing aortic valve replacement. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> We retrospectively evaluated 40 consecutive patients who underwent aortic valve replacement combined with a transaortic edge-to-edge mitral valve repair for 2+ or greater functional MR, between February 2002 and April 2015. The MR was graded semiquantitatively as 0 (trace/none), mild moderate (2+), or moderate to severe (3–4+). </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Thirty-two patients had aortic stenosis, and eight had aortic regurgitation. The mean ± standard deviation (SD) age was 77.5 ± 5 years, 34 (85%) were male, and the mean ± SD EuroSCORE II was 14.3% ± 12.9. At a median follow-up of 1 month (interquartile range, 0.75–10), there were significant improvements in preoperative versus postoperative median MR grade (3+ vs 1+, P &lt; 0.001), mean left ventricular ejection fraction (34% vs 41%, P = 0.018), left ventricular end-diastolic diameter (54 vs 49 mm, P = 0.005), and pulmonary artery systolic pressure (49 vs 35 mm Hg, P &lt; 0.001). Persistent 3 to 4+ MR occurred in two patients (5%). In 12 patients with at least 6-month follow-up (mean ± SD, 18 ± 11 months), a sustained improvement in all echocardiographic parameters was observed, with persistent 3 to 4+ MR occurring in one patient (8.3%). Actuarial survival at 1, 3, and 4.5 years was 82% ± 6, 71% ± 8, and 65% ± 10, respectively. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> A transaortic edge-to-edge repair for 2+ or greater functional MR can be safely performed during aortic valve replacement and is associated with improvements in MR grade, left ventricular remodeling, and pulmonary hemodynamics. </jats:p></jats:sec>

Transaortic repair of concomitant mitral insufficiency in patients with critical aortic stenosis undergoing aortic valvular replacement

“…[4,5,8,9,16,17] Currently, several studies have been published regarding the transaortic mitral repair technique in patients underwent AVR. [18][19][20] Nevertheless, Frederick and Woo [18] reported only seven patients; however, their results are consistent with our findings. In their study, all patients survived the immediate postoperative period with 100% survival at 30 days.…”

“…In their study, all patients survived the immediate postoperative period with 100% survival at 30 days. Mihos et al [19] published their 13-year-experience about transaortic mitral repair and reported that 32 patients underwent AVR due to severe AS and concomitant transaortic mitral repair with the Alfieri stitch. In addition, they concluded that transaortic edge-to-edge repair for ≥2+ functional MR could be safely performed during AVR and was associated with improvements in MR grade, pulmonary hemodynamics parameters, and left ventricular remodeling.…”

“…In addition, they concluded that transaortic edge-to-edge repair for ≥2+ functional MR could be safely performed during AVR and was associated with improvements in MR grade, pulmonary hemodynamics parameters, and left ventricular remodeling. [19] In addition, Choudhary et al [20] reported 16 patients who had moderate-to-severe MR and underwent aortic valve/root interventions. However, in their study, all patients had AI and the etiology and methodology were different from our study.…”

Aortic valve replacement in patients with a left ventricular ejection fraction ≤35% performed via a minimally invasive right thoracotomy

“…Approximately twothirds of the patients underwent a transaortic edge-to-edge MV repair, which avoids extensive mediastinal dissection and the need for an atriotomy, and requires approximately 10 additional minutes in operative time (19,20,31,32). Thus, the decreased surgical trauma afforded by this technique may be of particular benefit in high-risk patients (33). Strict selection criteria based on preserved annular and leaflet mechanics and anatomy as described herein, is of great importance to reduce the risk of recurrent mitral regurgitation given the lack of a ring annuloplasty, and to avoid the possibility of functional mitral stenosis (34,35).…”

Systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: a narrative review

“…It is performed by suture approximation of the A2 and P2 scallops of the anterior and posterior leaflets, creating a double-orifice MV and anchoring the coaptation point to prevent SAM (87). Benefits include the ability to perform via a transaortic approach which obviates the need for an atriotomy, a short operative time, and decreased surgical trauma (87)(88)(89). In a pooled analysis of 6 studies and 158 HCM patients who underwent septal myectomy and edge-to-edge MV repair, there was a significant reduction in LVOT gradient (82 vs. 16 mmHg), moderate or greater MR (84% vs. 5%), and presence of SAM (96% vs. 0%) at 2.8-year follow-up (P<0.001 for all).…”