Modified transventricular and transaortic mitral valve edge-to-edge repair mimicking MitraClip overcorrection

Figures

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  Modified mitral valve edge-to-edge repair mimicking MitraClip overcorrection.

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  Figure 1. Transventricular surgical view of the mitral valve showing the posterior (single white star) and anterior mitral leaflet (double white star). A left ventricular incision was made preferably in the center of scarred ventricular tissue and as far as possible away from relevant coronary arteries. Access to the mitral valve was obtained after placing stay sutures at the left ventricular wall (not shown). The P2 segment (white arrow) is located at the watershed of chordae tendinae, originating from anterolateral and posteromedial papillary muscle. A pledget-reinforced 4/0 Cardionyl U-suture was passed close to the annulus of the P2 segment (position 1) and then passed through a corresponding point of the anterior leaflet but closer to the free edge (position 2). The second arm of the suture was then passed closer to the free margin of both leaflets and tied (position 3 and 4). In this manner, effectivity of the technique can be improved by mimicking a MitraClip style overcorrection through solid buttressing behind the posterior leaflet that may lead to a reduction in the anteroposterior diameter of the mitral annulus.

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  Figure 2. Transaortic surgical view of the anterior mitral leaflet, following preparation of the aortic root for the Bentall's procedure. The button of the right coronary artery can be seen on the left side. Following the aortomitral curtain, the primary chordae tendineae of the anterior mitral leaflet at A2 segment were pulled laterally and apically through nerve hooks as shown, hereby the zenith of the watershed (white arrow) created from the primary chordae tendineae originating from the anterolateral and posteromedial pupillary muscle reaching the posterior mitral leaflet can easily be identified, indicating the P2 segment. Subsequently, stitches were placed as described in Figure 1. In summary, a pledget-reinforced 4/0 Cardionyl U-suture was passed close to the annulus of the P2 segment and then passed through a corresponding point of the anterior leaflet but closer to the free edge. The second arm of the suture was then passed closer to the free margin of both leaflets and tied.

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  Video 1. Shown is a summary of important findings of the current manuscript. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00032-3/fulltext.

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  Figure 3. The proportion of patients in each mitral valve stenosis grade over time. Four years postoperatively, none of the patients with echocardiographic follow-up had severe mitral valve stenosis (orange curve), whereas 11.9% of the patients had moderate (green curve, 95% CI, 2, 43.3), 73.8% mild (red curve, 95% CI, 42.8, 82), and 14.3% no (blue curve, 95% CI, 2.9, 50.7) mitral valve stenosis. The number of patients who had echocardiographic measurements at each time period is as follows: at 2 years, 19 patients; at 4 years, 10 patients; and finally at 6 years, 5 patients. CI, Confidence interval; MS, mitral valve stenosis.

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  Figure 4. Methods: From 2006 through 2015, 49 high-risk patients presented with aortic root or left ventricular aneurysm and concomitant secondary MR (2+- 4+). Forty-two patients underwent transaortic mitral edge-to-edge repair. Seven patients underwent transventricular mitral edge-to-edge repair. The Alfieri stitch technique was modified by MitraClip type overcorrection and solid buttressing behind the posterior leaflet. Results: Median echocardiographic follow-up time 39.2 (33.7-44.1) months. Median postoperative transvalvular gradient was low (2.72 mm Hg [1.91-4.22]) and did not increase during follow-up. The actuarial reoperation free rate at the index valve was 96.6%. Proportion of patients in each mitral valve stenosis grade over time. Implications: Transventricular or transaortic Alfieri mitral repair mimicking MitraClip overcorrection represents a safe technique and can be performed with low risk of creating mitral stenosis at midterm. The technique is straightforward, with reliable identification of the center of the valve leaflets being the limitation. MR, Mitral valve regurgitation; MS, mitral valve stenosis.

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  Figure E1. A consort diagram of our study. High-risk patients requiring aortic root surgery or left ventricular remodeling due to aortic root or left ventricular aneurysm in the presence of a secondary mitral valve regurgitation were eligible for transaortic or transventricular edge-to-edge repair. From December 2006 through April 2015, 7 patients (14%) underwent concomitant modified edge-to-edge mitral valve repair through a transventricular and 43 patients (86%) through a transaortic route. In the transaortic group, 1 procedure (2%) had to be abandoned intraoperatively due to a high transvalvular gradient. This patient was successfully treated by takedown of the edge-to-edge approximation and performance of mitral valve reconstruction using a standard annuloplasty-ring during a second pump run. MR, Mitral valve regurgitation.

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  Figure E2. Surgical view after transseptal approach of mitral valve. Posterior mitral leaflet is illustrated at the bottom (single white asterisk). The subvalvular apparatus of the posterior mitral leaflet is illustrated with a fan-shaped, flattened posterior papillary muscle with broad attachment of P2 chordae without division of direction. This represents a rare but possible anatomical arrangement of subvalvular apparatus. In such cases the detection of P2 segment via transaortic or transventricular route is challenging once a watershed of chordae tendinae originating from anterolateral and posteromedial papillary muscle indicating P2 segment is absent. The maximal height (white line) of the P2 segment may indicate the center of the leaflet.

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  Figure E3. Overview of surgical procedures. Forty-two patients (86%) underwent transaortic mitral valve edge-to-edge repair. Among them, 32 patients (65%) underwent aortic root replacement with reimplantation (N = 6) or replacement (N = 26) of the aortic root. Nine patients (18%) required aortic valve replacement (AVR) with concomitant coronary artery bypass grafting (CABG). In one case (2%) transaortic edge-to-edge repair was performed in a second pump run following replacement of the ascending aorta and CABG due to a progression of mitral valve regurgitation from moderate to severe. Seven patients (N = 14%) required CABG and left ventricular remodeling (Dor-Plasty). Thus, in those patients, mitral valve edge-to-edge repair was performed through a transventricular approach. TVR, Tricuspid valve repair.

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  Figure E4. Based on Kaplan–Meier analysis, overall survival was 66.5 ± 2% at 4 years.

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  Figure E5. The distribution of New York Heart Association (NYHA) classification before cardiac surgery and at latest follow-up. Preoperatively, the vast majority of the patients were in NYHA functional class III or IV (N = 48; 98%). At latest follow-up 10 of the 30 survivors (33%) were in NYHA functional class I, 16 (54%) in class II, 3 (10%) in class III, and 1 patient (3%) in class IV.