Myxomatous Disease Research Articles

Effects of Short-term Treatment with Pimobendan in Dogs with Myxomatous Valve Disease

Caro, A., Ynaraja, E. and Montoya, J.A. 2009. Effects of short-term treatment with pimobendan in dogs with myxomatous valve disease. J. Appl. Anim. Res., 35: 113–117. The aim of the study was to evaluate the short-term effects of pimobendan, a novel drug, in dogs with naturally occurring mitral valve myxomatous disease. The study involved twenty dogs with no previous treatment. The results show that pimobendan is well tolerated and can be administered effectively and safely in the treatment of congestive heart failure myxomatous mitral valve disease of the dog.

Echocardiographic assessment of mitral valve morphology and performance after triangular resection of the prolapsing posterior leaflet for degenerative myxomatous disease

The gold standard for the surgical treatment of prolapse of the posterior leaflet of the mitral valve (MV) for degenerative myxomatous disease has been represented by the quadrangular resection of the leaflet, according to the Carpentier technique. Since 2006 we performed a triangular resection of the prolapsing leaflet in 20 patients with myxomatous mitral regurgitation (MR). Seventeen patients (85%) underwent the triangular resection of P2; one patient (5%) had a triple scallops triangular resection (P1, P2, P3) and two (10%) a double scallops (P2, P3) resection. In this study, we report the immediate and mid-term clinical and echocardiographic results of a cohort of 20 patients, who underwent this technique. Thirty-day mortality was 0. Acute renal failure occurred in three patients (15%) and they resolved with conservative management. One patient (5%) required re-exploration for bleeding. At the mean follow-up of 13.1+/-4.2 months survival was 95%; one patient died of lymphoma during the follow-up time. All the cases were in New York Heart Association (NYHA) class I. Nineteen survivors underwent transthoracic echocardiography (TTE) (5), or transesophageal echocardiography (TEE) (13), performed by two skilled cardiologists. All patients showed no or trivial MV regurgitation. We believe that triangular resection of posterior MV leaflet (PMVL) provides excellent mid-term results providing the surgeon with a reliable and reproducible surgical option for myxomatous degenerative MV regurgitation.

Real-Time Three-Dimensional Transesophageal Echocardiography in the Intraoperative Assessment of Mitral Valve Disease

The aims of this study were to evaluate the feasibility of real-time 3-dimensional (3D) transesophageal echocardiography in the intraoperative assessment of mitral valve (MV) pathology and to compare this novel technique with 2-dimensional (2D) transesophageal echocardiography. Forty-two consecutive patients undergoing MV repair for mitral regurgitation (MR) were studied prospectively. Intraoperative 2D and 3D transesophageal echocardiographic (TEE) examinations were performed using a recently introduced TEE probe that provides real-time 3D imaging. Expert echocardiographers blinded to 2D TEE findings assessed the etiology of MR on 3D transesophageal echocardiography. Similarly, experts blinded to 3D TEE findings assessed 2D TEE findings. Both were compared with the anatomic findings reported by the surgeon. At the time of surgical inspection, ischemic MR was identified in 12% of patients, complex bileaflet myxomatous disease in 31%, and specific scallop disease in 55%. Three-dimensional TEE image acquisition was performed in a short period of time (60 +/- 18 seconds) and was feasible in all patients, with optimal (36%) or good (33%) imaging quality in the majority of cases. Three-dimensional TEE imaging was superior to 2D TEE imaging in the diagnosis of P1, A2, A3, and bileaflet disease (P < .05). Real-time 3D transesophageal echocardiography is a feasible method for identifying specific MV pathology in the setting of complex disease and can be expeditiously used in the intraoperative evaluation of patients undergoing MV repair.

Initial clinical experience with Myxo-ETlogix mitral valve repair ring

Complexity of mitral valve repair for myxomatous disease has led to low adoption. We report initial experience with a new ring designed specifically for myxomatous disease, the Myxo-ETlogix (Edwards Lifesciences LLC, Irvine, Calif). From March 15, 2006, through November 19, 2007, 129 patients underwent mitral valve surgery for pure myxomatous disease, and 124 valves (96.1%) were repaired. The Myxo-ETlogix ring was used in 100 cases and the Physio ring (Edwards) in 24. The Myxo-ETlogix design includes a 3-dimensional shape to reduce systolic anterior motion and a larger orifice to accommodate elongated leaflets and decrease need for sliding plasty. Direct mitral valve measurements were made. Sizing was based on A2 height, and choice of ring type was based on unresected leaflet heights. There was no operative mortality or lasting perioperative morbidity. The Myxo-ETlogix group had taller A2, P1, P2, and P3 leaflet segments than the Physio group (P < or = .003). Only 1 sliding plasty was performed for asymmetry in the Myxo-ETlogix group. Predischarge and follow-up echocardiograms (n = 338 in 124 patients) disclosed transient nonobstructive chordal systolic anterior motion in 3 echocardiograms in 3 patients. No patients had 2+ or greater mitral regurgitation. At discharge, 5.7% had 1+ mitral regurgitation; this proportion was 17.3% at last follow-up (mean 6.1 +/- 4.4 months). In initial experience with the Myxo-ETlogix ring, nonobstructive systolic anterior motion has been rare and obstructive systolic anterior motion not observed. Ongoing prospective echocardiographic and clinical studies will elucidate the role of this etiology-specific ring.

Evolving Concepts and Technologies in Mitral Valve Repair

Over the past few decades, it has become apparent that mitral valve repair is preferable to mitral valve replacement for the majority of patients undergoing surgery for mitral regurgitation (MR). The advantages of mitral valve repair include low rates of thromboembolism, resistance to endocarditis, excellent late durability reported for as long as 25 years, and no need for anticoagulation in the majority of patients.1–5 Because of these advantages of repair over replacement, the threshold for performing mitral valve repair has been lowered to include patients with MR who have early symptoms or even those who are asymptomatic, assuming that the chance of successful repair is ≥90% according to the latest American College of Cardiology/American Heart Association guidelines.6,7 Recently, surgeons have evaluated new techniques to further improve mitral valve repair, and cardiologists and surgeons are increasingly interested in the potential for percutaneous approaches to mitral valve repair.8 Myxomatous MR affects 1% to 2% of the population and therefore is a common pathology for mitral valve surgery, but the complexity of the operation may be difficult, which leads to generally low rates of repair. In a recent review, only 44.3% of patients in the United States who required mitral valve surgery for MR received a mitral valve repair,9 and in the Euro Heart Survey, repair rates were similarly low (46.5%).10 The goals of mitral repair are to maintain leaflet mobility, remodel the annulus, and allow normal coaptation of the anterior and posterior leaflets. Recent advances in techniques and new concepts for mitral repair are important to cardiologists and other clinicians interested in the management of patients with mitral valve disease. Accordingly, an improved understanding of these concepts will aid in the development of innovative techniques to create safe, durable, reliable, and reproducible mitral valve repair techniques, both …

Transesophageal Echocardiography of the Edge-to-Edge Technique of Mitral Valve Repair

A 66-year-old man with a history of a large anteroapical myocardial infarction presented to the operating room for three-vessel coronary artery bypass grafting and left ventricular (LV) reconstructive surgery (Dor procedure). His baseline intraoperative transesophageal echocardiography demonstrated a dilated LV with an end diastolic diameter 7 cm and an ejection fraction 20%. A central jet of severe mitral regurgitation (MR) was present, causing systolic flow reversal in the pulmonary veins. The mechanism appeared to be dilation of the mitral valve (MV) annulus and tethering of both the anterior and posterior leaflets. A coaptation defect was clearly seen along the entire commissural line (Video clip 1, Please see video clip available at www.anesthesia-analgesia.org). After initiation of cardiopulmonary bypass (CPB) and completion of the coronary artery bypass grafting, the LV was opened and a pericardial patch sewn into place to exclude the infarcted area of myocardium. Because of the high risk of the procedure and an already long bypass time (more than 2.5 h), the decision was made not to open another area of the heart to deal with the patient’s severe MR. Instead, before closing the LV, an Alfieri stitch was placed, using the double-orifice technique (Fig. 1). This was done to increase the area of coaptation between the two leaflets. The patient was successfully weaned from CPB with inotropes and an intraaortic balloon pump. Transesophageal echocardiography examination after chest closure showed only mild MR (Video

Quantitative Description of Mitral Valve Geometry Using Real-Time Three-Dimensional Echocardiography

: Leaflet and annular geometry are important determinants of mitral valve (MV) stress. Repair techniques which optimize valvular geometry will reduce stress and potentially increase repair durability. The development of such procedures will require image processing methodologies that provide a quantitative description of three-dimensional valvular geometry. Using three-dimensional echocardiography in conjunction with novel geometric modeling and rendering techniques, we have developed a high-resolution, quantitative, three-dimensional methodology for imaging the human MV. : Five normal adults underwent MV imaging using real-time three-dimensional echocardiography. Using specially designed image analysis software, multiple valvular geometric parameters, including the magnitude and orientation of leaflet curvature, leaflet surface area, annular height, intercommissural width, septolateral annular diameter, and annular area were determined for each subject. Image rendering techniques that allow for the clear and concise presentation of this detailed information are also presented. : Although three-dimensional annular and leaflet geometry were found to be highly conserved among normal human subjects, substantial regional variation in leaflet geometry was observed. Interestingly, leaflet geometric heterogeneity was most pronounced in the midposterior leaflet, the region most commonly involved in leaflet flail in subjects with myxomatous disease. : The image processing and graphical rendering techniques that we have developed can be used to provide a complete description of three-dimensional MV geometry in human subjects. Widespread application of these techniques to normal subjects and patients with MV disease will provide insight into the geometric basis of both valvular pathology and repair durability.

Flail mitral and tricuspid valves due to myxomatous disease

Myxomatous disease generally affects mitral valve. However, tricuspid valves also can be involved in 20% of the myxomatous mitral valve disease. Valve prolapse, elongation of chordae and chordae rupture are generally seen complications of the myxomatous disease. There are some reports about severe tricuspid regurgitation due to tricuspid valve prolapse and elongated chordae, but no tricuspid and mitral chordae ruptures in the same patient due to myxomatous disease have been reported. In this case tricuspid chordae rupture accompanied to mitral chordae rupture is discussed.

New techniques for percutaneous repair of the mitral valve

A variety of innovative techniques and devices are being developed for the percutaneous management of mitral insufficiency. More than 30 devices are in stages of development from early stage to human pivotal trials. Two devices for the management of degenerative myxomatous disease of the mitral valve replicate the Alfieri edge-to-edge surgical repair. One of those devices, the Evalve Mitraclip, is in a pivotal trial at the current time. The other devices address functional mitral regurgitation by a variety of techniques for performing mitral valve annuloplasty. The majority of devices take advantage of the proximity of the coronary sinus to the posterior mitral annulus to deliver devices that remodel the mitral annulus. Two devices perform septal lateral cinching decreasing the anterior posterior diameter of the mitral annulus and correcting leaflet malcoaptation. Numerous issues are discussed including regulatory hurdles and the integration of percutaneous techniques into clinical practice in a safe and efficacious manner.

Percutaneous Mitral Valve Repair

The mitral valve is a complex structure composed of the leaflets, annulus, chordae tendineae, and papillary muscles. Competency of the mitral valve is dependent on the proper function of each of these component structures. The pathophysiological triad of mitral regurgitation (MR) was originally described by Carpentier in 1983.1 It included the etiology of the valve lesion, the valve lesion itself, and the resultant valve dysfunction. He subsequently described a classification of leaflet dysfunction in MR that is commonly used and relevant for patient selection and evaluation of percutaneous mitral valve repair (PMVR). In type I dysfunction, there is normal leaflet motion, and valvular incompetence is due to either annular dilatation or leaflet perforation. Type II mitral dysfunction includes patients with increased leaflet motion (prolapse) of one or both leaflets so that there is failure of coaptation during systole resulting in mitral regurgitation. Patients in this category are those with degenerative myxomatous disease of the valve with chordal and/or papillary muscle elongation or rupture. Patients with type IIIa dysfunction have restriction of leaflet motion during both systole and diastole caused by leaflet and subvalvular apparatus thickening and fusion (rheumatic heart disease). The cause of valvular incompetence in patients with type IIIb dysfunction is restricted leaflet motion during systole caused by apical displacement of the papillary muscle from ventricular enlargement in dilated cardiomyopathy (functional MR) and lateral displacement of a posterior papillary muscle in ischemic MR. Patients may have a combination of causes of dysfunction (annular dilation, apical papillary muscle displacement), especially in advanced disease. Patients with MR for purposes of surgical and percutaneous intervention can broadly be categorized as having intrinsic disease (type II) and functional or ischemic (type I or type IIIb). Article p 2329 We are now embarking on a new era in the treatment of valvular heart …

Mitral Valve Surgery in the Adult Marfan Syndrome Patient

Because mitral valve dysfunction in adults with Marfan syndrome is poorly characterized, this study compares mitral valve pathophysiology and morphology with that of myxomatous mitral disease, documents types of mitral valve operations, and assesses long-term survival and durability of mitral valve surgery in Marfan patients. From May 1975 to June 2000, 27 adults with Marfan syndrome underwent mitral valve surgery. Their valve pathophysiology and morphology was compared with that of 119 patients with myxomatous mitral disease undergoing surgery from September 1995 to March 1999. Survival and repair durability were assessed at follow-up. Compared with myxomatous disease patients, Marfan patients had less posterior leaflet prolapse (44% versus 70%, p = 0.01), more bileaflet (44% versus 28%, p = 0.09) and anterior leaflet prolapse (11% versus 3%, p = 0.07), and presented earlier for surgery (age 41 +/- 12 years versus 57 +/- 13, p < 0.0001). Marfan patients had longer and thinner leaflets. Mitral valve repair was performed less frequently in Marfan (16 of 27, 59%) than myxomatous disease patients (112 of 119, 94%). There were no hospital deaths; at 10 years, survival was 80% and freedom from reoperation 96%, with only 1 reoperation among the 16 repairs. Mitral valve pathophysiology and morphology differ between Marfan and myxomatous mitral valve diseases. Valve repair in Marfan patients is durable and gives acceptable long-term results, even in adults who present with advanced mitral valve pathology. With increasing use of the modified David reimplantation operation and sparing of the aortic valve, mitral valve repair is a greater imperative, particularly since we have not had to reoperate on any Marfan patients with reimplantations.

Plástica valvar mitral pela técnica de "Duplo Teflon" em pacientes com anel valvar calcificado e degeneração mixomatosa

OBJETIVO: O objetivo deste estudo é apresentar resultados imediatos e tardios da plástica da valva mitral pela técnica de Duplo Teflon, em pacientes com insuficiência mitral importante que apresentam anel valvar gravemente calcificado e degeneração mixomatosa. MÉTODO: Entre 1985 e 2002, 162 pacientes com insuficiência mitral devido à degeneração mixomatosa foram submetidos a plástica da valva mitral no Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo. Deste total, 13 pacientes que apresentavam anel valvar gravemente calcificado foram submetidos à plástica da valva com ressecção quadrangular e anuloplastia pela técnica de Duplo Teflon. A idade média dos pacientes foi 65,4 +/- 12,9 anos, e 69,2% dos pacientes eram do sexo masculino. Um (7,7%) paciente tinha doença coronariana associada e foi submetido à cirurgia de revascularização do miocárdio. No período pré-operatório, 15,4% dos pacientes estavam em classe funcional IV, 69,2% em classe III e 15,4% em classe II. RESULTADOS: Não houve óbito no período pós-operatório imediato. No período pós-operatório tardio, 90,9% dos pacientes vivos estavam em classe funcional I. Não houve complicações como hemólise ou endocardite. Um paciente foi reoperado no segundo mês do período pós-operatório sendo realizada troca da valva mitral. A sobrevida atuarial em 14 anos foi 71,4 +/- 17,1%. CONCLUSÃO: A plástica da valva mitral com a técnica de Duplo Teflon, em pacientes com insuficiência mitral importante devido à degeneração mixomatosa e anel valvar gravemente calcificado, apresentou taxa de sobrevida satisfatória e boa evolução clínica, sugerindo ser melhor alternativa em relação à troca valvar.

&lt;![CDATA[&lt;B&gt;Mitral valve repair using the double Teflon technique in patients with severely calcified annuli and myxomatous disease&lt;/B&gt;]]&gt;

&lt;![CDATA[&lt;B&gt;Mitral valve repair using the double Teflon technique in patients with severely calcified annuli and myxomatous disease&lt;/B&gt;]]&gt;

The Clinical Development of Percutaneous Heart Valve Technology: A Position Statement of The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography and Interventions (SCAI)

The Clinical Development of Percutaneous Heart Valve Technology: A Position Statement of The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography and Interventions (SCAI)

INVITED COMMENTARY

A new useful application of the edge-to-edge (E2E) technique is described in this article by Mascagni and colleagues. Four patients affected with mitral regurgitation due to prolapse of the posterior leaflet from chordal rupture had mitral valve repair and developed postrepair systolic anterior motion and left ventricular outflow tract obstruction that were refractory to volume expansion and medical treatment with β-blockers. All four patients had redundancy of the anterior leaflet as seen in Barlow's disease. Surprisingly, 2 of these patients received a sliding plasty as part of the repair in an attempt to reduce the height of the posterior leaflet and prevent systolic anterior motion with left ventricular outflow tract obstruction. Using the E2E technique mitral valve replacement was avoided, and the normally functioning (no stenosis and no insufficiency) normal valve was preserved. Thus, all the benefits of reconstructive mitral valve surgery were not denied to these 4 patients. Mitral valve replacement would have been highly undesirable in these patients whose lesions were easily amenable to valve repair. Patients are well aware that reconstructive mitral valve surgery offers a totally normal life without restrictions in activity and without anticoagulation, and is clearly better than valve replacement. With these expectations, patients accept surgery in the early phase of the disease, often before occurrence of symptoms. The effectiveness of the E2E technique in the specific clinical context of refractory postoperative systolic anterior motion allowed the expectations of these 4 patients to be fulfilled. Although the reported follow-up period is short, excellent long-term results can be predicted [1Alfieri O. Maisano F. De Bonis M. et al.The double-orifice technique in mitral valve repair: a simple solution for complex problems.J Thorac Cardiovasc Surg. 2001; 122: 674-681Abstract Full Text Full Text PDF PubMed Scopus (662) Google Scholar]. It is important to emphasize that the stitch (or stitches) should be placed at least 1 cm away from the free edge of the leaflets to substantially reduce redundancy of the leaflets and prevent protrusion of valve tissue into the left ventricular outflow tract. This principle is consistently applied by us when the E2E repair is used to correct mitral regurgitation in Barlow's disease, in which redundancy of the leaflets is a peculiar feature [2Maisano F. Schreuder J.J. Oppizzi M. et al.The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique.Eur J Cardiothorac Surg. 2000; 17: 201-205Crossref PubMed Scopus (154) Google Scholar]. In our large experience with Barlow's disease treated by the E2E technique (> 400 cases), postoperative systolic anterior motion requiring valve replacement never has occurred. The experience reported in this article also suggests use of the E2E repair for idiopathic hypertrophic subaortic stenosis, in which the mitral valve protrudes into the left ventricular outflow tract and is responsible for the pressure gradient and often for symptoms. Although this solution has been sporadically attempted, data are scanty and are definitely not convincing [3Bhudia S.K. McCarthy P.M. Smedira N.G. et al.Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings.Ann Thorac Surg. 2004; 77: 1598-1606Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar]. In an attempt to correct mitral regurgitation before left ventricular dilatation occurs, a higher prevalence of postoperative systolic anterior motion can be expected. The message delivered by this article should be remembered to offer an easy solution to a difficult problem.

Long-term outcome after mitral valve repair

Background. Several studies reported excellent long-term results after mitral valve repair for regurgitation, however a number of patients still experience recurrent mitral valve regurgitation which requires reoperation. We have evaluated the long-term outcome of a consecutive series of patients who underwent mitral valve repair for regurgitation in an attempt to identify the risk factors associated with late failures. Patients and methods. One-hundred and sixty-four patients underwent mitral valve repair for ischemic and degenerative mitral valve regurgitation. Seventy-two patients underwent echocardiographic evaluation a median of 5.6 years after surgery. Results. Ten-year survival freedom from any fatal cardiac event was 75.9% and survival freedom from redo mitral valve surgery was 93.8%. Multivariable analysis showed that residual mitral valve regurgitation grade > 1 as assessed during the immediate postoperative period (at 10-year, 60.6% vs. 95.7%, p = 0.001, RR 20.7, 95%C.I. 3.4–125.3) and chronic obstructive pulmonary disease/asthma (at 10-year 66.8% vs. 95.2%, p = 0.013, RR 12.0, 95%C.I. 1.7–85.2) were predictors of redo mitral valve surgery. The same findings were observed also among patients with myxomatous degenerative disease. At echocardiographic follow-up, no significant improvement was detected in terms of left ventricular ejection fraction, whilst mitral valve regurgitation grade (median, 3 to 1), New York Heart Association class (median, 2 to 1) and left atrium diameter (median, 50 to 44 mm) decreased significantly. Conclusions. This study confirms the excellent clinical long-term results after mitral valve repair. An adequate repair technique is advocated in order to decrease the immediate postoperative rate of residual regurgitation > 1 as this is a main determinant of late failures requiring redo mitral valve surgery. Further studies are required to better define the possible causative role of chronic obstructive pulmonary disease and any underlying connective tissue metabolic disorder in late failures after mitral valve repair.

Valve-sparing aortic root replacement in Marfan syndrome

Marfan syndrome is the most common inherited connective tissue disorder, affecting approximately 1 in 10,000 live births. The cardinal features of Marfan syndrome are the abnormalities of the skeleton (tall stature, arachnodactyly, and joint hyperelasticity), eye (lens subluxation), and aorta (root aneurysm with proclivity toward rupture and dissection). Aortic catastrophe accounts for most of the premature mortality among Marfan patients, a risk that climbs steeply during adolescence and results in death of half of Marfan patients by the age of 40 years. Most of the improvement in life expectancy that has been achieved in Marfan syndrome is attributable to early recognition of aortic root aneurysms and prophylactic replacement with composite grafts (mechanical valve prostheses within Dacron conduits) before rupture or dissection occurs. Despite the excellent early and late results with composite grafts, there has been growing interest in operative procedures that replace the sinuses but preserve the aortic valve leaflets, to avoid anticoagulation and minimize the risk of prosthesis-related endocarditis. These procedures are still in evolution and late results are not yet known, but as with mitral repair in the setting of myxomatous disease, valve-sparing procedures in Marfan syndrome have weathered a storm of initial criticism and skepticism and are steadily gaining acceptance.

Biomechanical and echocardiographic characterization of flail mitral leaflet due to myxomatous disease: Further evidence for early surgical intervention

Biomechanical and echocardiographic characterization of flail mitral leaflet due to myxomatous disease: Further evidence for early surgical intervention

Biomechanical and echocardiographic characterization of flail mitral leaflet due to myxomatous disease: further evidence for early surgical intervention

Background Flail mitral leaflet (FML) is a common complication of mitral valve prolapse, often leading to severe mitral regurgitation (MR) and left ventricular dysfunction. In the absence of timely surgical correction, survival is significantly impaired. Early recognition of FML and identification of risk factors is important because early intervention increases the chances of survival. Methods We studied 123 patients undergoing mitral valve surgery for severe MR caused by myxomatous disease. Chart review, echocardiography, and tensile testing were performed. Results Thirty-eight patients had FML, and 85 patients had non-flail mitral leaflet (non-FML). Patients with FML were younger (53.7 ± 1.8 vs 59.3 ± 1.4 years, P = .02), had more severe MR (3.89 ± 0.04 vs 3.76 ± 0.04, P = .02), were less likely to be in New York Heart Association class III or IV heart failure (5% vs 20%, P = .037), and were less likely to have bileaflet mitral valve prolapse (5% vs 38%, P <.001) than non-FML patients. Valve tissue from patients with FML had less stiff chordae (23.5 ± 3.6 vs 59.1 ± 11.7 Mpa, P = .006) that tended to have a lower failure stress (3.8 ± 0.9 vs 9.6 ± 2.2 Mpa, P = .07) and had more extensible leaflets (56.4% ± 7.9% vs 42.9% ± 2.7% strain, P = .04) compared with that of non-FML patients. Conclusions The development of FML may result from intrinsic tissue abnormalities and is associated with a distinct subset of the myxomatous population. Identification of such clinical characteristics in this population and knowledge of an implicit mechanical abnormality of valve tissue may further the argument for early surgical correction.

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

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.