Asian Cardiovasc Thorac Ann 2003;11:131-134
© 2003 Asia Publishing EXchange Ltd
Mitral Regurgitation: Comparison Between Edge-to-Edge Repair and Valve Replacement
Jai Raman, PhD,
Pallav Shah, MCh,
Siven Seevanayagam, FRACS,
John Cheung, FRCSEd,
Brian Buxton, FRCS
Department of Cardiac Surgery, Austin Hospital, Melbourne, Australia
For reprint information contact: Jai Raman, PhD Tel: 61 3 9496 5399 Fax: 61 3 9496 5292 email: mardi.malone{at}austin.org.au Department of Cardiac Surgery, Austin Hospital, Heidelberg, Melbourne, Victoria 3084, Australia.
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ABSTRACT
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Mitral regurgitation due to bileaflet prolapse and ischemic causes can be difficult to repair. Midterm experience of the Alfieri edge-to-edge repair as an alternative to valve replacement is reported. Twenty-six patients with severe mitral regurgitation underwent the Alfieri repair between January 1998 and December 2000 (group 1); 15 cases were due to bileaflet prolapse and 7 were of ischemic origin. During the same period, valve replacement was performed in 36 patients (group 2), 20 of whom had similar indications. Follow-up was complete to a mean of 15 months (range, 1–28 months). There was no early death in either group. During follow-up, there was no reoperation in group 1, while 2 patients in group 2 required reoperations due to prosthetic valve endocarditis. There were 4 major thromboembolic or bleeding events in group 2, and none in group 1. All patients in group 1 had trivial to mild mitral regurgitation on follow-up echocardiography. The mean mitral valve gradient was significantly higher in group 2 compared to group 1 (7.2 versus 3.2 mm Hg, p = 0.001). The edge-to-edge repair is associated with good early and midterm results. Long-term follow-up is required to evaluate the durability of this technique.
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INTRODUCTION
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The edge-to-edge technique for repairing the mitral valve (MV), thereby creating a double-orifice MV, was first described in 1998 by Maisano and colleagues1 who applied it predominantly in the treatment of Barlow disease. Since then, a few other groups have adapted this technique for other indications such as ischemic mitral regurgitation (MR) and severe bileaflet prolapse.2 Recent large studies have shown that MV repair confers a long-term survival benefit over valve replacement.3,4 Patients with MR due to degenerative anterior leaflet prolapse or restricted leaflet motion as in ischemic disease may not be easily amenable to valve repair and are usually treated by valve replacement. We have extended the repair criteria for such patients at our center. We report our midterm results using the Alfieri edge-to-edge technique in this difficult group of patients, and compare them with those of a similar group receiving MV replacement.
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PATIENTS AND METHODS
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Twenty-six patients with severe MR (group 1) underwent MV reconstruction by Alfieri edge-to-edge repair at the Austin & Repatriation Medical Centre between January 1998 and December 2000. During the same period, prosthetic MV replacement was performed in 36 patients (group 2), 20 of whom had similar indications for surgery as group 1. Both groups had similar preoperative baseline patient characteristics. The mean age was 65.01 ± 10.18 years in group 1 and 60.12 ± 8.80 years in group 2. The male-to-female ratio was 18:8 in group 1 and 8:28 in group 2. The mean preoperative New York Heart Association functional class was 3.38 ± 0.60 in group 1 and 3.31 ± 0.62 in group 2. In both groups, 80% of the patients were in sinus rhythm and 20% had atrial fibrillation preoperatively. The left ventricular ejection fraction was above 45% in 85% of the study population. No concomitant procedures were carried out except in one patient in group 1 who underwent repair of an inferior left ventricular aneurysm. Table 1
summarizes the etiopathology of MV disease in both groups. Degenerative MV disease (58%) was the main reason of valve repair in group 1, while rheumatic fever (44%) was the main reason for valve replacement in group 2. A 27-mm St Jude mechanical valve (St Jude Medical, Inc., St Paul, MN, USA) was used in 17/36 patients and a 25-mm valve was used in 12/36. All patients in both groups were followed up clinically and by echocardiogram at yearly intervals.
The MV was accessed through the superior biatrial transseptal approach. Valve morphology was analyzed and the valve was carefully assessed and tested. Edge-to-edge repair alone was sufficient to correct MR in 88% of cases. Additional reconstructive procedures were carried out in 3 patients (12%): 2 had leaflet resection with primary reconstruction, and one with infective endocarditis had patch repair of the perforation. A corresponding point of maximum prolapse was identified in both leaflets. A simple 5/0 Gore-Tex suture was passed through these 2 areas in the anterior and posterior leaflets, and the valve was tested with antegrade blood cardioplegia delivered through the aortic root or by a saline injection into the left ventricle. If the valve looked reasonably competent at this stage, the Gore-Tex suture was passed once more in a figure-of-eight fashion and tied down. This suture was over-locked with another suture of 4/0 Ti-Cron (United States Surgical, Norwalk, CT, USA) to prevent slipping of the Gore-Tex knots and to provide additional reinforcement to the Gore-Tex stitch.5 The Alfieri edge-to-edge repair results in a double-orifice MV in cases of bileaflet prolapse, and a smaller valve orifice in ischemic MR and when the prolapse is close to the commissure. A posterior annuloplasty band (Cosgrove Ring; Baxter Healthcare Corp., Deerfield, IL, USA) was implanted in 24 patients. There were two exceptions: one patient early in the experience had an edge-to-edge repair without annuloplasty, and another underwent repair of the valve through an inferior left ventricular aneurysm. After reconstruction in all cases, the valve area was measured with Hegar dilators passed through the orifices; a global valve area of more than 2.5 cm2 was considered acceptable. All repairs were evaluated by intraoperative transesophageal echocardiography. There were 3 intraoperative conversions to MV replacement after attempted repair because of residual moderate MR; 2 of these patients had severe bileaflet prolapse and one had ischemic MR.
During the same time period, 36 patients underwent prosthetic MV replacement at our institution. Mitral valve replacement was carried out with chordal preservation of the anterior and posterior leaflet in 32 patients, and posterior leaflet only in 4 patients.
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RESULTS
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There were no perioperative deaths. All patients were reviewed clinically and by echocardiography at yearly intervals. Follow-up was completed in all patients. The mean period of follow-up was 15.5 months (range, 1 to 28 months). The mean New York Heart Association functional class at the last follow-up was similar in both groups (1.38 ± 0.60 in group 1 and 1.46 ± 0.58 in group 2, p = 0.5446). In group 1, there was one late noncardiac death (due to cancer). There were 3 intraoperative conversions to MV replacement because of residual moderate MR in patients with severe bileaflet prolapse; these patients were not included in further analyses. There were no reoperations on follow-up. One patient had progression of coronary artery disease, necessitating reoperation for coronary artery bypass grafting; the MV was evaluated prior to surgery and showed mild MR. At the time of the last follow-up, the grade of MR was insignificant or trivial in 17/23 patients (74%) and mild in 6/23 (26%). The grade of MR remained stable throughout the follow-up and was similar to that observed on echocardiography intraoperatively and immediately pre-discharge. There was no major bleeding or thromboembolic complication. None of the patients needed long-term anticoagulation. Short-term anticoagulation was required only in patients with atrial fibrillation.
In group 2, there was one late sudden death in a patient with poor left ventricular function. Two reoperations for prosthetic valve endocarditis were performed with no mortality. There were 2 major bleeding episodes and 2 major thromboembolic events. On follow-up echocardiography, the mean MV gradient was significantly lower (p = 0.0012) in group 1 (3.2 ± 2.9 mm Hg) compared with group 2 (7.2 ± 3.3 mm Hg). The gradient across the MV repair in group 1 remained stable throughout the follow-up and was similar to that noted in the immediate postoperative and pre-discharge echocardiography.
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DISCUSSION
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The Alfieri edge-to-edge repair converts the MV orifice from a single inflow channel to a two-orifice channel. However, similar to the congenital anatomical variant of double-orifice valve, the valve leaflets in this kind of repair are adequately supported by chordae. The attraction of this technique is that the native valve is utilized. As a result, many of the complications traditionally associated with prosthetic mechanical valve replacement of the MV, such as anticoagulant-related hemorrhage, thromboembolism, and increased risk of endocarditis, are minimized by preserving the native valve.4 Mitral valve repair for degenerative MV disease has been shown to be durable in the long term.6 Its efficacy and low complication rate have prompted the use of repair even in patients with mild or no symptoms.7
The edge-to-edge repair technique works on a single mechanism: the forced coaptation in the middle of the leaflet. This repair reduces the height of the leaflets at their middle portion and lowers the level of coaptation below the annulus.8 The annuloplasty increases the coaptation without affecting the global orifice area. This combined approach not only restores a competent valve, but also decreases the stress on the leaflet surface, thus reducing the risk of long-term degeneration. A further advantage of this technique is that it abolishes systolic anterior motion of the anterior leaflet by fixing its free edge.
In spite of the satisfactory long-term results from Alfieri’s group8,9 (94.4% ± 2.59% survival and 90% ± 3.37% freedom from reoperation at 5 years), this technique has not achieved widespread acceptance. We felt it was important to compare this technique with an alternative which is MV replacement in most centers. Our results show that all patients in the valve repair group were asymptomatic with trivial to mild MR and lower transmitral gradients on follow-up echocardiography. Further, none of the patients required reoperation for valve repair failure. This indicates that the repairs were very durable on intermediate-term follow-up. In addition, preservation of the native valve reduced infective, bleeding, thromboembolic, and reoperative complications in this group compared to the valve replacement group, and we also found that the transmitral gradients in a resting state were lower than those in the valve replacement group. A reduction of the global postoperative MV area or a functional induction of mitral stenosis, especially during exercise, is thought to be a major drawback of the edge-to-edge repair. However, it has been demonstrated that its performance is comparable to the single-orifice valve in the fluid dynamic model.8 It was also shown that the repair was not associated with substantial transval vular obstruction during high-flow conditions in an animal model.10
Like Alfeiri’s group,8,9 we believe that the edge-to-edge repair technique is indicated essentially for complex lesions with a lower probability of repair: prolapse of both leaflets, prolapse of the anterior leaflet, extensively calcified posterior annulus, and restricted leaflet motion as in rheumatic and ischemic diseases. In these complex lesions, the repair markedly reduced the incidence of valve replacement. This study was limited by the small number of patients in both groups, which did not permit an adequate statistical analysis to be carried out. In addition, the follow-up of patients was only intermediate term. Nevertheless, it was concluded that MV repair using the edge-to-edge technique is a versatile alternative to MV replacement in MR due to bileaflet involvement or ischemia, with a lower risk of morbidity, and good early and midterm results. The clinical outcome was favorable in terms of MR, transmitral gradients, and valve-related complications in the intermediate term. The technique was found to be simple, safe, and reproducible. Mitral valves that traditionally have been considered difficult to repair may be repaired by the edge-to-edge technique with good results, but long-term follow-up is required to evaluate the durability of this repair.
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REFERENCES
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ABSTRACT
INTRODUCTION
