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Mid-term outcome of the edge-to-edge mitral valve repair via aortic outflow tract in high risk patients.

The edge-to-edge mitral valve repair technique, invented by Alfieri and colleagues, introduced valve repair as a treatment option for patients with complex diseases where standard annuloplasty and related repair techniques are insufficient, due to annular calcification and patient frailty. We retrospectively evaluated the results of a transaortic edge-to-edge mitral valve repair (Alfieri stitch) in high risk patients who were undergoing aortic valve replacement. From February, 2012 to December, 2017, 43 patients underwent transaortic edge-to-edge mitral valve repair with concomitant aortic valve replacement at a single institution. Preoperative and postoperative echocardiograms were compared. Home telephone follow up was conducted and postoperative morbidity was examined, including the need for reoperation, stroke and cardiac arrhythmia. 30-day and long-term survival rates were also determined. Mitral regurgitation (MR) was graded semi-quantitatively as 0 (trace/none), mild (1), moderate (2) or moderate to severe (3 - 4). The patients were 74 ±7.8 years old. 65 % of the patients were male. Mean cardiopulmonary bypass time was 115±37 min and mean cross-clamp time was 71±23 min. There was a significant improvement in preoperative versus postoperative median MR grade (2 (IQR 2-3) vs 0 (IQR 0-1); p<0.05). Follow-up transthoracic echocardiograms in 29 patients obtained at a median of 9 months (range 3 - 19 months) and in 16 patients at a median of 34 months postoperatively (range 21 - 53 months) showed mild (1 (IQR 1-2)) grade of mitral regurgitation. 30-day survival was 98%. Long term survival at 12 and 24 months were 88% and 81% respectively. Mitral valve reoperation was conducted in one patient (2 %), who was suffering of endocarditis. Stroke occurred in 2 patients (7 %). Cardiac arrhythmia was observed in 15 patients (35 %). 8 patients (19 %) suffered from atrial fibrillation and 7 patients (16 %) displayed atrioventricular blockage. 10 patients (23 %) could be treated conservatively and 5 patients (12 %) needed implantation of a pacemaker. Transaortic edge-to-edge mitral valve repair can be safely performed during aortic valve replacement in high risk patients and improves even long-term MR grade. Postoperative cardiac arrhythmia occurs frequently. 66 % of them could be treated successfully by conservative procedures.