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J Thorac Cardiovasc Surg 2001;122:674-681
© 2001 The American Association for Thoracic Surgery
Surgery for Aquired Cardiovascular Disease (ACD) |
From the Division of Cardiac Surgery, IRCCS S. Raffaele Hospital, Milan, Italy.
Received for publication Oct 16, 2000. Revisions requested Nov 13, 2000; revisions received April 9, 2001. Accepted for publication April 30, 2001. Address for reprints: Ottavio Alfieri, MD, Divisione di Cardiochirurgia, Ospedale S. Raffaele, Via Olgettina 60, 20132, Milano, Italy (E-mail: ottavio.alfieri{at}hsr.it).
Abstract
Objective: The aim of this study is to report our results with the central doubleorifice technique used for the treatment of complex mitral valve lesions.
Methods: The central double-orifice repair has been used in 260 patients (mean age, 56 ± 14.3 years) over a period of 7 years. The mechanism responsible for mitral regurgitation was prolapse of both leaflets in 148 patients, prolapse of the anterior leaflet in 68, prolapse of the posterior leaflet with annular calcification or other unfavorable features in 31, and lack of leaflet coaptation for restricted motion or erosion of the free edge in 13. Degenerative disease was the cause of mitral regurgitation in 80.8% of the patients, rheumatic disease was the cause in 9.6%, endocarditis was the cause in 6.1%, and ischemic disease was the cause in 2.3%.
Results: Hospital mortality was 0.7%, and the overall survival at 5 years was 94.4% ± 2.59%. Thirteen patients required a reoperation (2 early postoperatively and 11 late during the follow-up), for an overall freedom from reoperation of 90.0% ± 3.37% at 5 years. Freedom from reoperation was lower in patients with rheumatic valve disease and in patients who did not undergo an annuloplasty procedure.
Conclusions: The effectiveness and durability of the central double-orifice technique were assessed in this study. This type of repair can be a useful addition to the surgical armamentarium in mitral valve reconstruction.
Repair of a regurgitant mitral valve is superior to mitral valve replacement, with lower hospital mortality, longer survival, better preservation of ventricular function, fewer thromboembolic complications, and reduced risk of endocarditis.
1 Therefore, it is desirable to extend the population of patients who can benefit from mitral valve reconstruction.
The most common cause of degenerative mitral regurgitation (MR) is a floppy (myxomatous) valve with segmental prolapse of the posterior leaflet. 2 This lesion can be corrected by means of quadrangular resection of the prolapsing portion of the posterior leaflet, with highly reproducible and durable results. 3 Other lesions, however, are associated with less-gratifying results, require more complex and surgically demanding techniques, or both, and many surgeons are hesitant to perform a reconstructive operation under these circumstances. For instance, correction of MR caused by anterior leaflet prolapse is less predictable than posterior leaflet repair, and the poor results obtained with anterior leaflet resection have led to other more complex and less reproducible techniques, such as chordal shortening, chordal transposition, and chordal replacement. 4-8 Similarly, prolapse of both leaflets in severe myxomatous degeneration (Barlow disease) represents a challenging surgical problem requiring a number of different maneuvers directed toward the leaflets and the entire subvalvular apparatus. Prolonged aortic crossclamp times have been reported for the correction of bileaflet prolapse, 9 and immediate and long-term results can be affected by the complexity of the surgical procedure. In the presence of an extensively calcified posterior anulus, decalcification is required to allow annular plication for conventional quadrangular resection, as described by el Asmar and colleagues, 10 but this maneuver is potentially dangerous, time consuming, and not easily reproducible. Also, MR as a result of restricted leaflet motion caused by rheumatic or ischemic disease may represent a condition not easily amenable to valve repair by the conventional techniques.
Mitral valve reconstruction on the basis of the approximation of the free edge of the leaflets at the site of regurgitation (edge-to-edge technique) has been quite effective in the afore-mentioned complex situations. 11-13 When the approximation of the free edge of the leaflets is carried out centrally, away from the commissural area, a double-orifice mitral valve is artificially created. In this article the effectiveness of the edge-to-edge technique resulting in a double-orifice mitral valve configuration is confirmed on the basis of a large body of experience, and the stability of the results over time is assessed.
Methods
Patients
From October 1992 through March 2000, of 902 consecutive patients with pure MR undergoing valve operations, 861 (95.5%) underwent valve repair. In 260 patients regurgitation was corrected by the central double-orifice technique. We excluded 82 patients in whom the edge-to-edge suture was not placed in the central portion of the leaflets; that is, it was on either P1 or P3 scallops of the posterior leaflet at or near the commissure. There were 155 male and 105 female patients, with a mean age of 56 ± 14.3 years (range, 17-79 years). At admission, 83 (31.9%) patients were in New York Heart Association (NYHA) functional class I, 68 (26.1%) were in class II, 104 (40.0%) were in class III, and 5 (1.9%) were in class IV. One hundred ninety-eight (76.1%) patients were in sinus rhythm, and 62 (23.9%) had preoperative atrial fibrillation.
The cause of the disease is shown in Table 1. In the great majority of the cases, degenerative disease was the cause of MR.
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Four patients had a previous cardiac operation: coronary artery bypass surgery (1 patient); correction of coarctation of the aorta (1 patient), aortic valve replacement (1 patient), and mitral valve repair with an annuloplasty ring (1 patient).
Left ventricular ejection fraction was above 45% in 242 (93.0%) patients and below this level in 18 patients. Patients who underwent a central double-orifice valve repair in the context of the Batista operation were not included in this analysis.
Surgical technique
The technique has been described before. 11-13 In brief, a doubleorifice mitral valve is created by approximating the free edges of the leaflets at the site of regurgitation, usually with a running 4-0 polypropylene suture. In case of very thin leaflets, 1 or more U-shaped 5-0 polypropylene stitches reinforced with pledgets are used.
The operation is currently carried out through a conventional midline sternotomy during normothermic cardiopulmonary bypass with the use of intermittent cold-blood cardioplegia. The mitral valve is approached through the left atrium, with the incision done in the interatrial groove.
More recently, the operation has been performed through a minimally invasive approach by Port-Access cannulation (10 patients; Heartport, Inc, Redwood City, Calif) and robotic technology (3 patients).
An annuloplasty with or without a prosthetic ring was associated in 208 (80.0%) patients; it was not carried out when the anulus was not dilated (8 patients) or in cases of severely calcified anulus (44 patients). In 83.5% of the patients, the central double-orifice technique alone was sufficient to correct MR, whereas in less than one fifth of the patients, additional reconstructive procedures (eg, leaflet resection, implantation of artificial chordae, patch repair of perforation, and chordal transposition) were concomitantly performed as indicated.
In all cases after reconstruction, 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 for "normal-size" patients. Competence was evaluated by means of forceful injection of saline solution into the left ventricle.
Other cardiac procedures were associated as needed: coronary artery bypass grafting (10 patients); radiofrequency ablation of atrial fibrillation (9 patients); tricuspid valve annuloplasty (7 patients); aortic valve replacement (9 patients); aortic valve repair (3 patients); correction of atrial septal defect (4 patients); and other operations (4 patients).
Mean cardiopulmonary bypass time and aortic crossclamp time were 54 ± 14.9 and 39 ± 8.9 minutes, respectively. Excluding patients undergoing associated cardiac procedures, mean cardiopulmonary bypass and ischemic times were 48 ± 8.5 and 33 ± 5.7 minutes, respectively.
Patients in whom a prosthetic ring was implanted received short-term (3 months) anticoagulation. No long-term anticoagulation was prescribed, unless atrial fibrillation was present or a prosthetic aortic valve was also inserted.
Follow-up
Follow-up information was obtained for all hospital survivors and was 100% complete. The mean period of follow-up was 2.0 ± 1.74 years (range, 1 month to 7 years), for a cumulative follow-up of 529 patient-years. Data were collected either through outpatient visit or by telephone contact with the patient or the referring physician in the period ranging from April 1 to April 30, 2000.
Statistical analysis
Data were analyzed with the statistical package JMP for Macintosh (SAS Institute, Inc, Cary, NC). Preoperative variables included in the models were age, sex, cause, mechanism of regurgitation, NYHA class, annuloplasty, annular calcification, associated aortic valve replacement, and associated coronary artery bypass grafting. The baseline characteristics and outcomes were compared by 
2 analysis for categorical data and t tests for continuous variables. Survival and freedom from reoperation were analyzed with Kaplan-Meier actuarial methods. Comparison among groups was done according to the log-rank method. Outcomes were evaluated multivariately by stepwise logistic regression analysis. The variables included in the model were selected among those reaching a P value of .25 or less at univariate analysis. Results are reported as means ± standard deviation; for actuarial estimates, standard error is reported instead.
Results
Mortality
Two patients died in the hospital, for an overall 0.7% operative mortality. A 68-year-old woman submitted to mitral and aortic valve repair, who had a normal preoperative coronary angiogram, died of untreatable coronary spasm (angiographically documented), causing perioperative myocardial infarction in the first postoperative day. Another patient died 1 week postoperatively of right ventricular failure and subsequent multiple organ failure. Both patients had a competent nonstenotic mitral valve at echocardiography. There were 5 late deaths: 2 were noncardiac (cancer) in origin, and 3 were cardiac (2 sudden deaths and 1 for documented acute myocardial infarction). The actuarial overall survival at 5 years was 94.4% ± 2.59% (Figure 1).
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Reoperation
One patient required early reoperation for residual MR, and 1 required early reoperation for mitral stenosis. In the latter case the atrioventricular obstruction was found at the subvalvular level at transesophageal echocardiography. The mechanism of stenosis was hypertrophy of the papillary muscles, with impingement in the orifices of the valve.
There were 11 late reoperations, for an overall freedom from reoperation of 90.0% ± 3.37% at 5 years (Figure 2). The cause of reoperation was recurrent severe MR, except in 1 case, in which the cause was severe hemolysis as a result of partial detachment of the prosthetic ring and trivial MR. Disruption of the edge-to-edge suture exclusively occurred in the 2 patients with endocarditis. In 8 patients a new prolapse of the valve was the cause of MR, either because of new chordal rupture or chordal elongation. In only 2 patients was rerepair of the valve carried out. No patients required late reoperation for mitral valve stenosis. Freedom from reoperation was 91% ± 3.7% at 5 years in the degenerative disease group, 72% ± 14.5% in the rheumatic group, and 93% ± 6.7% in the endocarditis group. No patient with an ischemic cause of MR required reoperation during the follow-up period (P = .06, Figure 3).
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Discussion
The techniques of mitral valve repair developed and popularized by Carpentier 4 are the basis of the conservative approach to mitral valve surgery and are extensively used in our institution. The central double-orifice technique has been essentially reserved for patients with severe MR caused by complex lesions requiring demanding (although effective) surgical techniques for correction or with an expected lower probability of successful repair, namely, prolapse of both leaflets, prolapse of the anterior leaflet, or prolapse of the posterior leaflet in the presence of an extensively calcified anulus. Also, a small number of patients with restricted leaflet motion caused by rheumatic or ischemic disease were conveniently treated with the central double-orifice technique, as were patients with erosion of the free edge of the leaflets. After the introduction of the central double-orifice technique, the percentage of patients with pure MR treated with mitral valve reconstruction is approximately 95%. Many patients in this series underwent the operation when they were still relatively asymptomatic or with few symptoms, despite severe MR. This strategy, which is consistent with the concept that early intervention is associated with a positive effect on the natural history of the disease, 14 reflects our confidence in the central double-orifice technique as a method that can provide an effective and durable repair, even in the presence of complex lesions. Along with early operation, a minimally invasive approach is now often requested, particularly by young women, who are understandably reluctant to undergo a major operation with no or few symptoms. On the basis of our limited experience, even complex lesions, such as bileaflet prolapse in Barlow disease, can be effectively corrected with the central double-orifice technique through a minithoracotomy with the Heartport system for cardiopulmonary bypass. The central double-orifice procedure can be carried out in a short period of time, as demonstrated by the duration of cardiopulmonary bypass and aortic crossclamping time in this series. This is particularly convenient when associated procedures are needed and in patients with poor preoperative conditions or with advanced left ventricular dysfunction. The central double-orifice repair is technically simple, but careful evaluation of the mitral valve is always mandatory, and considerable judgment is required in selecting the right site for the approximation of the leaflets and the appropriate extension of the suture. The surgeon should aim at the complete elimination of the MR, minimizing the reduction of the valve area. Inadequate application of the technique may result either in residual MR or in mitral stenosis. When the leaflets are particularly redundant, as in Barlow disease, the suture should also aim at the reduction of the height of the leaflets to prevent systolic anterior movement of the anterior leaflet. The technical details of the central double-orifice repair as a standardized approach to treat MR in the setting of Barlow disease have been published previously. 13
In the present study, early and late mortality were totally unrelated to the technique of repair. The incidence of early and late complications was low, as in the other series of patients treated with mitral valve reconstruction. Left ventricular dysfunction was the main determinant of the persistence of symptoms in the presence of a well-functioning valve. Considering the type of lesions treated in this series, freedom from reoperation at 5 years was satisfactory. Also, with the central double-orifice technique, the reoperation-free survival was lower in the group of patients with rheumatic disease, a finding already reported by other authors. 4,15 Because of the small number of patients with ischemic MR in the present study, the role of the central double- orifice technique in this difficult setting is not clearly defined. When an annuloplasty was not carried out, freedom from reoperation was significantly lower. Because an annuloplasty was mostly avoided in patients with an extensively calcified anulus, we can conclude that the central doubleorifice repair, although attractive in this setting, is not a panacea and can be associated with suboptimal results. A limitation of this study is that the echocardiographic data obtained during the period of follow-up are not reported. This is due to the fact that the majority of the patients were referred to us from remote geographic areas, and therefore the echocardiographic examinations were performed locally, inevitably with a large variety of criteria of interpretation.
In conclusion, the present study confirms the favorable results obtained with the central double-orifice technique and also demonstrates the durability of the repair at least up to 5 years of follow-up. We are aware that similar results can be obtained with other techniques of repair evolved through the years, and therefore we propose the central doubleorifice technique as an effective alternative approach that can be a useful addition to the surgical armamentarium in mitral valve reconstruction.
Appendix: Discussion
Dr D. Craig Miller (Stanford, Calif). Congratulations, Dr Maisano, for a fine presentation. You have represented Dr Alfieri&'s group well at previous meetings, and today is no exception. After having just heard the world&'s largest experience from the citadel of the "Alfieri stitch," as we call it—although out of modesty Professor Alfieri terms it the "edge-to-edge technique"—I thought it would be helpful for the audience to take you through the last 5 years of the literature with respect to what we have learned about this technique. The original 1995 Fucci paper showed that the edge-to-edge repair was employed in 35 cases out of 299, or only 12% of their repairs. In this early learning phase it probably was used as a "bail-out" maneuver often, that is, where after a conventional repair persistent problems such as residual anterior leaflet prolapse were identified and the leaflets were therefore sutured together. Then, at the 1997 EACTS meeting in Copenhagen your group had applied the edge-to-edge technique in 28% of 432 patients. In your overall experience presented today, this fraction is now up to 35% of mitral repairs; perhaps most importantly, it was the only procedure you performed on the leaflets per se in 75% of these Alfieri patients. Now, why is that? You are obviously gaining more confidence in this procedure, but some of this increased usage is due to the fact that you are doing an Alfieri stitch in a growing subpopulation of young patients with Barlow&'s syndrome. You presented at the EACTS meeting in Glasgow last September that all you do is a 2 to 3-cm long running stitch between the billowing central portions of the leaflets in these Barlow&'s cases without any leaflet resection. Should we really abandon leaflet resection and Carpentier&'s original techniques and just do this? Or, conversely, is your 75% usage of only the edge-to-edge technique without other leaflet procedures due to this large minority, possibly a majority, of Barlow patients?
Dr Maisano. Thank you, Dr Miller. We are now applying the double-orifice technique to an increasing percentage of patients undergoing valve repair at our institution. In the last year, about 35% of the valve-repair operations included the edge-to-edge technique, largely because our hospital has gained experience in the treatment of Barlow disease, and it has become the referring center for this condition in our country. On the basis of our experience, leaflet resection is not necessary in most cases of leaflet prolapse when it is an integrated part of a severe form of Barlow disease. In this case we simply rely on a single running suture in the middle of the leaflets; this single maneuver is effective in most cases of bileaflet prolapse, even when one leaflet is flail.
Dr Miller. You have proven that it does restore competence in patients with Barlow&'s, but how does it reduce the length of the elongated chordae and leaflet tissue? You talked about that in your paper published in The European Journal of Cardio-Thoracic Surgery a couple of months ago, but please tell us how big these bites are you taking. You say "big bites" of the leaflets, but they must be real "Texas-size bites" as Dr Cooley would say, that is, 1-cm to 2-cm bites, to reduce the excessive overall length of the chordae and billowing leaflets.
Dr Maisano. I think there are 2 possible answers for this intriguing question. One is that by taking big bites, the height of the leaflets is reduced, and the tissue redundancy is diminished; moreover, the stitch is placed at the limit of the rough zone to force coaptation in this physiologic area. A second explanation can be related to the dynamics of valve closure: the presence of a central stitch implies coaptation early in the systolic phase, when the left ventricular volume is higher and the length of the subvalvular apparatus matches the long axis of the ventricle.
Dr Miller. Does that mean that the postoperative echo shows you actually are not eliminating the persistent hooding and billowing characteristics of these Barlow leaflets, but the valve no longer leaks?
Dr Maisano. No, we usually see no billowing after the double-orifice technique, with the coaptation level well below the annular plane, whereas in Barlow disease it is usually above it before the repair. However, there are a few cases with residual billowing and without leak.
Dr Miller. Then perhaps Houdini is still alive and lives in Milano, because somehow you are eliminating a lot of excess tissue in these Barlow patients. I guess I will have to visit your unit to understand completely what happens to all the surfeit of chordal and leaflet tissue.
This is a little disappointing to me because I believed your Alfieri stitch would be a great trick where you had an extensively and severely calcified posterior mitral anulus that you do not want to decalcify, but are you telling us today in those 50 cases or so where you did not use a ring for various reasons that you have more failures or recurrence of MR?
Dr Maisano. We observed that the nonuse of the ring is a risk factor for reoperation; however, I should point out that patients undergoing the double-orifice technique are part of a selected population at high risk either of valve repair failure or of perioperative adverse outcome. In patients with a severely and extensively calcified anulus, another possible approach is the annular decalcification, which we believe is, at least in our hands, a very risky procedure, especially in older patients. We decided to approach this situation with the double-orifice technique whenever possible. Unfortunately, in most of these patients, the leaflet lesions are associated with some degree of annular dilatation, and we leave this anomaly untreated by solely doing a double-orifice procedure. Although soon after cardiopulmonary bypass discontinuation, there was no one patient with MR of more than mild severity, in some cases it has progressed, and it has been the reason for reoperation in some patients in our series.
Dr Miller. Does that mean today you are decalcifying the atrioventricular groove under the posterior anulus?
Dr Maisano. No, we still think that this is a very dangerous maneuver, and we try to avoid it. However, we are aware of the risk of recurrent MR in these patients.
Dr Miller. I agree it can be a very dangerous maneuver, especially in the elderly, and should be undertaken only in carefully selected circumstances.
My next point is good news/bad news situation. What do you think of the cardiologists taking your Alfieri stitch to the catheterization laboratory and doing mitral valve repairs outside the surgical arena? Has any of this been done yet it Italy? It is now rumored to have been done in Brazil, Eastern Europe, and even California.
Dr Maisano. I am aware that there is a program at Columbia University about this topic, but we do not have direct experience with it. A device able to staple together 2 leaflets can be designed, but some limitations still exist to its introduction in clinical practice. First of all, it is not easy to decide the site of stapling and to control its position. Second, an annuloplasty cannot be added to the procedure, and this has to be considered mandatory in most cases.
Dr Miller. Let&'s hope that will stop, or at least delay, our cardiology colleagues, but I am not as sanguine that it will.
Now, your old colleagues from Brescia, after you and Ottavio Alfieri moved to Milano, will be presenting a paper at this year&'s American Heart Association meeting showing that in patients with anterior leaflet prolapse, one of the predictors of valve repair failure is poor left ventricular systolic function. I presume these data were obtained from your original patients operated upon in Brescia. We all used to think, based on Theo Art&'s theoretical models from over 25 years ago, that where you sew the leaflets together is a low stress point. Do you really think that is so in dilated, poorly contracting ventricles? We have some animal data where we did the Alfieri procedure with a strain transducer which show that it is, indeed, a low-stress point under basal or normal resting conditions, but becomes a high-stress point if you induce acute left ventricular ischemia and the ventricle and mitral anulus dilate. What do you expect your results will be in patients with these bad ventricles?
Dr Maisano. This is a very stimulating question. In our experience we did not find any correlation between left ventricular function and failure of the repair, but you pointed out that the stress on the leaflets is higher in the presence of ventricular dysfunction, and this may have an influence on the strain on the double-orifice suture. However, we use an annuloplasty ring in all cases of cardiomyopathy, and this procedure reduces the stress on the leaflets.
Dr Miller. My final question relates to that point—ischemic MR where morphologically normal leaflets can leak severely due to geometric changes in the subvalvular apparatus and left ventricle. You now have applied the edge-to-edge technique in 14 patients with ischemic MR according to your manuscript. What do you think the role of the Alfieri stitch is in patients with ischemic MR, with or without an annuloplasty ring?
Dr Maisano. I believe the edge-to-edge technique has an important role in the treatment of ischemic MR. However, MR is an almost unknown disease, and any procedure has to be applied to the basis of the exact knowledge of the mechanism of regurgitation. For instance, in case of papillary muscle dysfunction, a paracommissural edge-to-edge repair, associated with ring annuloplasty to reduce the tethering effect, is a fast and effective solution. In other patients, when the regurgitant jet is central, a double-orifice repair can be done, but we still do not know whether this technique should be alternative or complementary to undersized annuloplasty. I believe this is one of the most stimulating issues in cardiac surgery today, and our group is dedicated to the research of the insights of this disease.
Dr Miller. Therefore, you are saying you would not rely on an Alfieri stitch alone? It sounds to me that what you are describing is just a posteromedial commissuroplasty.
Ischemic MR conceivably could be the biggest application for this procedure, which otherwise most surgeons still consider to be just a "bail-out" method.
Finally, I would like to compliment you where you caution us in your paper that you do not really have comprehensive late echo follow-up on your patients and you simply do not know how well these repaired valves are functioning. Could you just give us your personal subjective impression of the degree of residual MR in those patients who have been studied postoperatively in Milano?
Dr Maisano. We decided not to include the Doppler echocardiographic data in our article because we do not have a sufficient number of examinations available. As I said before, most of our patients come from a broad area, throughout Italy, and follow-up in our department is difficult. We collected data from about 150 patients studied at our echocardiography laboratory. What we have seen is that all patients have significant reduction of the valve area after the repair, as expected. The mitral valve area goes to a mean of about 3.5 cm2 from a preoperative value of about 9 cm2; this reduction does not tend to increase over time.
Dr Miller. In those 150 patients, what about persistent or recurrent MR?
Dr Maisano. Of the subgroup with a postoperative long-term Doppler echocardiographic study performed at our institution, we have 15 patients with residual MR grade 2/4, 7 with grade 3/4, and 2 with severe MR. Among these patients are included those who underwent reoperation at our institution.
Footnotes
Read at the Twenty-sixth Annual Meeting of The Western Thoracic Surgical Association, The Big Island, Hawaii, June 21-24, 2000. 
References
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2006 WRITING COMMITTEE MEMBERS, R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, October 7, 2008; 118(15): e523 - e661. [Full Text] [PDF]
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R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., September 23, 2008; 52(13): e1 - e142. [Full Text] [PDF]
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H. Hasegawa, Y. Araki, A. Usui, J. Yokote, S. Saito, H. Oshima, and Y. Ueda Mitral valve motion after performing an edge-to-edge repair in an isolated swine heart J. Thorac. Cardiovasc. Surg., September 1, 2008; 136(3): 590 - 596. [Abstract] [Full Text] [PDF]
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T. K. Rosengart, T. Feldman, M. A. Borger, T. A. Vassiliades Jr, A. M. Gillinov, K. J. Hoercher, A. Vahanian, R. O. Bonow, and W. O'Neill Percutaneous and Minimally Invasive Valve Procedures: A Scientific Statement From the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology, Functional Genomics and Translational Biology Interdisciplinary Working Group, and Quality of Care and Outcomes Research Interdisciplinary Working Group Circulation, April 1, 2008; 117(13): 1750 - 1767. [Abstract] [Full Text] [PDF]
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P. W.M. Fedak, P. M. McCarthy, and R. O. Bonow Evolving Concepts and Technologies in Mitral Valve Repair Circulation, February 19, 2008; 117(7): 963 - 974. [Full Text] [PDF]
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M. J. Mack Percutaneous treatment of mitral regurgitation: so near, yet so far! J. Thorac. Cardiovasc. Surg., February 1, 2008; 135(2): 237 - 239. [Full Text] [PDF]
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M. LeBoutillier III and V. J. DiSesa Valvular and Ischemic Heart Disease Card. Surg. Adult, January 1, 2008; 3(2008): 1175 - 1192. [Full Text]
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H. Morimoto, K. Tsuchiya, M. Nakajima, Y. Mitsumori, and K. Kato Chordal Replacement with Temporary Alfieri Stitch for Anterior Leaflet Prolapse Asian Cardiovasc Thorac Ann, December 1, 2007; 15(6): 531 - 533. [Abstract] [Full Text] [PDF]
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L. R. Croft, J. H. Jimenez, R. C. Gorman, J. H. Gorman III, and A. P. Yoganathan Efficacy of the Edge-to-Edge Repair in the Setting of a Dilated Ventricle: An In Vitro Study Ann. Thorac. Surg., November 1, 2007; 84(5): 1578 - 1584. [Abstract] [Full Text] [PDF]
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T. A. Timek, S. L. Nielsen, D. T. Lai, D. Liang, G. T. Daughters, N. B. Ingels Jr, and D. C. Miller Effect of Chronotropy and Inotropy on Stitch Tension in the Edge-to-Edge Mitral Repair Circulation, September 11, 2007; 116(11_suppl): I-276 - I-281. [Abstract] [Full Text] [PDF]
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L. Coats and P. Bonhoeffer NEW PERCUTANEOUS TREATMENTS FOR VALVE DISEASE Heart, May 1, 2007; 93(5): 639 - 644. [Full Text] [PDF]
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U. Sartipy, A. Albage, E. Mattsson, and D. Lindblom Edge-to-Edge Mitral Repair Without Annuloplasty in Combination With Surgical Ventricular Restoration Ann. Thorac. Surg., April 1, 2007; 83(4): 1303 - 1309. [Abstract] [Full Text] [PDF]
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P. V. Anagnostopoulos, N. Alphonso, L. Nolke, L. K. Hornberger, G. W. Raff, A. Azakie, and T. R. Karl Neonatal Mitral and Tricuspid Valve Repair for In Utero Papillary Muscle Rupture Ann. Thorac. Surg., April 1, 2007; 83(4): 1458 - 1462. [Abstract] [Full Text] [PDF]
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L. Kiraly, M. Hubay, A. C. Cook, S. Y. Ho, and R. H. Anderson Morphologic features of the uniatrial but biventricular atrioventricular connection J. Thorac. Cardiovasc. Surg., January 1, 2007; 133(1): 229 - 234. [Abstract] [Full Text] [PDF]
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M. Kuduvalli, S. V. Ghotkar, A. D. Grayson, and B. M. Fabri Edge-to-Edge Technique for Mitral Valve Repair: Medium-Term Results With Echocardiographic Follow-Up. Ann. Thorac. Surg., October 1, 2006; 82(4): 1356 - 1361. [Abstract] [Full Text] [PDF]
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J. H. Jimenez, J. Forbess, L. R. Croft, L. Small, Z. He, and A. P. Yoganathan Effects of annular size, transmitral pressure, and mitral flow rate on the edge-to-edge repair: an in vitro study. Ann. Thorac. Surg., October 1, 2006; 82(4): 1362 - 1368. [Abstract] [Full Text] [PDF]
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R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): e1 - e148. [Full Text] [PDF]
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Y.-Q. Lai, X. Meng, T. Bai, C. Zhang, Y. Luo, and Z.-G. Zhang Edge-to-Edge Tricuspid Valve Repair: An Adjuvant Technique for Residual Tricuspid Regurgitation Ann. Thorac. Surg., June 1, 2006; 81(6): 2179 - 2182. [Abstract] [Full Text] [PDF]
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U. Da Col, G. Bardelli, I. Di Bella, G. Minniti, and T. Ragni Echocardiographic images in mitral valve repair by "edge to edge" technique Eur Heart J Cardiovasc Imaging, June 1, 2006; 7(3): 247 - 249. [Abstract] [Full Text] [PDF]
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J.-M. Frapier, C. Sportouch, V. Rauzy, P. Rouviere, S. Cade, R. G. Demaria, J.-M. Davy, and B. Albat Mitral valve repair by Alfieri's technique does not limit exercise tolerance more than Carpentier's correction Eur J Cardiothorac Surg, June 1, 2006; 29(6): 1020 - 1025. [Full Text] [PDF]
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M. J. Mack Percutaneous Mitral Valve Repair: A Fertile Field of Innovative Treatment Strategies Circulation, May 16, 2006; 113(19): 2269 - 2271. [Full Text] [PDF]
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D. R. Brinster, D. Unic, M. N. D'Ambra, N. Nathan, and L. H. Cohn Midterm Results of the Edge-to-Edge Technique for Complex Mitral Valve Repair. Ann. Thorac. Surg., May 1, 2006; 81(5): 1612 - 1617. [Abstract] [Full Text] [PDF]
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H. Kasegawa, T. Shimokawa, I. Shibazaki, H. Hayashi, T. Koyanagi, and T. Ida Mitral valve repair for anterior leaflet prolapse with expanded polytetrafluoroethylene sutures. Ann. Thorac. Surg., May 1, 2006; 81(5): 1625 - 1631. [Abstract] [Full Text] [PDF]
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F. Langer, F. Rodriguez, A. Cheng, S. Ortiz, T. C. Nguyen, M. K. Zasio, D. Liang, G. T. Daughters, N. B. Ingels, and D. C. Miller Posterior mitral leaflet extension: An adjunctive repair option for ischemic mitral regurgitation? J. Thorac. Cardiovasc. Surg., April 1, 2006; 131(4): 868 - 877. [Abstract] [Full Text] [PDF]
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A. M. Calafiore, M. Di Mauro, A. L. Iaco, V. Mazzei, G. Teodori, S. Gallina, L. Weltert, M. Samoun, and G. Di Giammarco Overreduction of the Posterior Annulus in Surgical Treatment of Degenerative Mitral Regurgitation Ann. Thorac. Surg., April 1, 2006; 81(4): 1310 - 1316. [Abstract] [Full Text] [PDF]
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Y.-Q. Lai, Y. Luo, C. Zhang, and Z.-G. Zhang Utilization of Double-Orifice Valve Plasty in Correction of Atrioventricular Septal Defect Ann. Thorac. Surg., April 1, 2006; 81(4): 1450 - 1454. [Abstract] [Full Text] [PDF]
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M. A. Borger, A. Alam, P. M. Murphy, T. Doenst, and T. E. David Chronic Ischemic Mitral Regurgitation: Repair, Replace or Rethink? Ann. Thorac. Surg., March 1, 2006; 81(3): 1153 - 1161. [Abstract] [Full Text] [PDF]
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L. H. Cohn Percutaneous Mitral Valve Repair With the Edge-to-Edge Technique: A Surgeon's Perspective J. Am. Coll. Cardiol., December 6, 2005; 46(11): 2141 - 2142. [Full Text] [PDF]
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N. C. Dang, M. S. Aboodi, T. Sakaguchi, H. S. Wasserman, M. Argenziano, D. M. Cosgrove, T. K. Rosengart, T. Feldman, P. C. Block, and M. C. Oz Surgical Revision After Percutaneous Mitral Valve Repair With a Clip: Initial Multicenter Experience Ann. Thorac. Surg., December 1, 2005; 80(6): 2338 - 2342. [Abstract] [Full Text] [PDF]
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M. Oc, G. Doukas, C. Alexiou, B. Oc, L. Hadjinikolaou, A. W. Sosnowski, and T. J. Spyt Edge-to-Edge Repair With Mitral Annuloplasty for Barlow's Disease Ann. Thorac. Surg., October 1, 2005; 80(4): 1315 - 1318. [Abstract] [Full Text] [PDF]
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F. Langer, F. Rodriguez, S. Ortiz, A. Cheng, T. C. Nguyen, M. K. Zasio, D. Liang, G. T. Daughters, N. B. Ingels, and D. C. Miller Subvalvular Repair: The Key to Repairing Ischemic Mitral Regurgitation? Circulation, August 30, 2005; 112(9_suppl): I-383 - I-389. [Abstract] [Full Text] [PDF]
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R. A. Levine and E. Schwammenthal Ischemic Mitral Regurgitation on the Threshold of a Solution: From Paradoxes to Unifying Concepts Circulation, August 2, 2005; 112(5): 745 - 758. [Full Text] [PDF]
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T. A. Vassiliades Jr, P. C. Block, L. H. Cohn, D. H. Adams, J. S. Borer, T. Feldman, D. R. Holmes, W. K. Laskey, B. W. Lytle, M. J. Mack, et al. 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) Endorsed by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1554 - 1560. [Full Text] [PDF]
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T. A. Vassiliades Jr, P. C. Block, L. H. Cohn, D. H. Adams, J. S. Borer, T. Feldman, D. R. Holmes, W. K. Laskey, B. W. Lytle, M. J. Mack, et al. 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) Ann. Thorac. Surg., May 1, 2005; 79(5): 1812 - 1818. [Full Text] [PDF]
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F. Maisano, A. Redaelli, M. Soncini, E. Votta, L. Arcobasso, and O. Alfieri An Annular Prosthesis for the Treatment of Functional Mitral Regurgitation: Finite Element Model Analysis of a Dog Bone-Shaped Ring Prosthesis Ann. Thorac. Surg., April 1, 2005; 79(4): 1268 - 1275. [Abstract] [Full Text] [PDF]
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R. Mascagni, N. Al Attar, M. Lamarra, S. Calvi, A. Tripodi, A. Mebazaa, and A. Lessana Edge-to-Edge Technique to Treat Post-Mitral Valve Repair Systolic Anterior Motion and Left Ventricular Outflow Tract Obstruction Ann. Thorac. Surg., February 1, 2005; 79(2): 471 - 473. [Abstract] [Full Text] [PDF]
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A. M. Gillinov Chordal transfer for repair of anterior leaflet prolapse MMCTS, January 1, 2005; 2005(0118): mmcts.2004.000901 - mmcts.2004.000901. [Abstract] [Full Text] [PDF]
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T. Fukuda, I. Kashima, and S. Yoshiba Surgically created double orifice repair of tricuspid regurgitation in infants with congenital heart disease J. Thorac. Cardiovasc. Surg., October 1, 2003; 126(4): 1220 - 1221. [Full Text] [PDF]
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J. X. Qin, T. Shiota, P. M. McCarthy, C. R. Asher, M. Hail, D. A. Agler, Z. B. Popovic, N. L. Greenberg, N. G. Smedira, R. C. Starling, et al. Importance of Mitral Valve Repair Associated With Left Ventricular Reconstruction for Patients With Ischemic Cardiomyopathy: A Real-Time Three-Dimensional Echocardiographic Study Circulation, September 9, 2003; 108(2011): II-241 - II-246. [Abstract] [Full Text] [PDF]
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 G. Gatti and P. Pugliese Preliminary experience in mitral valve repair using the Cosgrove-Edwards annuloplasty ring Interact CardioVasc Thorac Surg, September 1, 2003; 2(3): 256 - 261. [Abstract] [Full Text] [PDF]
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